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 COLLEGE OF PHYSICIANS 
 AND SURGEONS 
 
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SURGERY 
 
 ITS PRINCIPLES ANT) l^RACTTCE 
 
 FOR ST[TDENTS AND PRACTITIONERS 
 
 BY 
 
 ASTLEY PASTON CoOPER ASHHUIIST. A.B., M.D., F.A.CS 
 
 INSTRUCTOR IN SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, ASSOCIATE SURGEON TO THE 
 
 EPISCOPAL HOSPITAL AND ASSISTANT SURGEON TO THE PHILADELPHIA ORTHOP-EDIC 
 
 HOSPITAL AND INFIRMARY FOR NERVOUS DISEASES 
 
 WITH 7 COLORED PLATES AND 1032 ILLUSTRATIONS IN THE TEXT 
 MOSTLY ORIGINAL 
 
 LEA & FEBIGER 
 
 PHILADELPHIA AND X E \V YORK 
 
Entered according to the Act of Congress, in the N-ear 1914, bj^ 
 
 LEA & FEBIGER, 
 in the Office of the Librarian of Congress. All rights reserved. 
 
TO 
 
 RICHARD H. HARTE 
 
 A SIRGEOX OF WIDE CLINICAL EXPERIENCE 
 
 AX ABLE TEACHER 
 
 A WISE CONSULTANT 
 
 A SAFE AND SKILFUL OPERATOR 
 
 THIS VOLUME 
 
 IS GRATEFULLY DEDICATED 
 BY HIS PUPIL, ASSISTANT AND FRIEND 
 
 THE AUTHOR 
 
I'liKKACK. 
 
 I'j" is the function of a work such as this to furnish the foundation 
 on which a knowledjje of Surgery is to be built. Didactic and chnical 
 lectures, i)apers in current journals, classical monographs, and par- 
 ticularly the student's clinical work and the surgeon's daily practice 
 are valuable adjuncts, but unless the foundations have been laid 
 broad and deep, no useful superstructure can be erected. 
 
 A text-book shoukl afford a true perspective, placing the various 
 branches of study in their proper relative position, maintaining their 
 just proportions, and providing a source of information which shall 
 indicate where further knowledge is to be gained. A student seeks 
 clear and accurate statements, and desires to have facts set definitely 
 before him. If the present volume supplies these wants, if it helps 
 the student to learn surgery and proves a useful reference work for 
 the practitioner, it will have fulfilled its purpose. 
 
 Every text-book, however, has its limitations. At best it can but 
 teach the student to know; it cannot teach him to do. And though 
 knowledge is power, much practical experience in laboratory, dis- 
 pensary and hospital wards must supplement didactic instruction. 
 In the present work emphasis is placed on the underlying principles, 
 and pathogenesis, diagnosis^ and indications for treatment have 
 received particular attention. Descriptions of operations, however, 
 have not been slighted. The more important operations have been 
 described in detail, and in every case an attempt has been made to 
 present clearly, if briefly, at least one method of operative procedure. 
 The specialties of the Eye, the Ear, the Nose, and the Throat naturally 
 are not included; and Genito-urinary Surgery, Gynecology, and 
 Orthopedics have been discussed only so far as they come within 
 the province of the general surgeon. 
 
 Neither publishers nor author have spared any pains in the endeavor 
 to furnish a text-book on Surgery w^hich shall be acceptable to the 
 profession. The illustrations, with very few exceptions, are entirely 
 original, and are reproductions of photographs or sketches made by 
 the writer in his various services, especially at the Episcopal Hospital 
 of Philadelphia. To his long association with this Hospital he owes 
 unsurpassed opportunities for clinical work; as well as to his associa- 
 tion with the Orthopaedic Hospital, and to his former services at the 
 Pennsylvania, the Children's, and the German Hospitals. Most of 
 the skiagraphs are derived from the Episcopal Hospital, and were 
 made by Dr. Thomas S. Stew^art or his Assistant, Dr. A. U. Wilkinson. 
 
vi PREFACE 
 
 Those from the Orthopiedic Hospital were made by Dr. Wm. \nn 
 Korb. The ilhistrations of operative technique are based largely on 
 work done in the writer's Laboratory of Operative Surgery in the 
 I'niversity of Pennsyhaiiia. The credit for converting the author's 
 diagrams and photographs into admirable illustrations is due to 
 Mr. Charles F. Bauer. 
 
 Much help has been derived from other text-l)ooks and systems of 
 surgery. First and foremost among these must be mentioned the 
 Principles and Practice of Surgery of John Ashhurst, Jr. The indebted- 
 ness of the writer of the present work to that \olume can be appre- 
 ciated best by those who, like himself, acquired the basis of their 
 surgical education from its pages. Every other source of inff)rmation 
 has been studiously sought; and, thanks to the facilities afforded by 
 the Library of the College of Physicians of Philadelphia, this laborious 
 task has been rendered comparatively easy. It was thought inadvis- 
 able to cumber the text with bibliographical references, but the dates 
 of publication of authoritative contributions, whether recent or of 
 historical interest, have been indicated, and it is believed that by this 
 means the original references may be more easily found in the Index 
 Medicus or in the I^idex Catalogue of the Surgeon- GeneraVs Library, 
 U. S. Army. The author is particularly indebted to the Avritings 
 of Deaver on abdominal and prostatic surgery; and free citations 
 have been made from the \olumes pu])lishcd In- this brilliant surgeon 
 in collaboration with the writer. 
 
 The text of the present volume has receixcd the criticisms of several 
 of the author's friends. Dr. Henry Winsor and Dr. Penn-Gaskell 
 Skillern, Jr., have devoted themselves to this work most unselfishly, 
 and have offered many valuable corrections and suggestions. Dr. 
 G. G. Davis and Dr. Frank D. Dickson have kindly reviewed the 
 chapters on Orthopedic Surgery and on Diseases of the Joints. Dr. 
 A. D. Whiting has assisted in reading the proof-sheets, and has made 
 the index. 
 
 A. P. C. A. 
 
 811 Spruce Street, Philadelphia, 1914. 
 
( onti:nts. 
 
 GENERAL SURGERY. 
 
 ("HAPTKR I. 
 Inflammation' 17 
 
 CHAPTER II. 
 Diseases Resulting from Inflammation 47 
 
 CHAPTER 111. 
 MoDiFiKU Forms of Inflammation (^8urc;ical Infections) .... 7t) 
 
 CHAPTER IV. 
 
 Tl-MOHS 101 
 
 CHAPTER V. 
 SuROK.'AL Techniqie 133 
 
 CHAPTER VI. ' 
 I.nmuries and their Effects 159 
 
 CHAPTER VII. 
 Gunshot Wounds 180 
 
 CHAPTER VIII. 
 Amp[t.\tions 192 
 
 CH.M'TER IX. 
 
 Effects of Heat and Cold; Injuries by Electric Currents, Lightning 
 
 AND the Rontgex Rays; Skin-grafting and Plastic Surgery . . 217 
 
viii CONTENTS 
 
 SYSTEMIC SURGERY. 
 
 CHAPTER X. 
 .Surgery of the BLOOD-VASfULAU System 227 
 
 CHAPTER XI. 
 
 Surgery of the Skin, Bur.s.-e, Lymphatics, Muscles, Tendons, and 
 
 Nerves 259 
 
 CHAPTER XII. 
 Fractures 294 
 
 CHAPTER XHI. 
 Injuries of Joints . 385 
 
 CHAPTER XIV. 
 
 Diseases of Bone 416 
 
 CHAPTER XV. 
 
 Diseases of Joints 451 
 
 CHAPTER XVI. 
 Orthopedic SuRCiERY ^^4 
 
 REGIONAL SURGERY. 
 
 CHAPTER XVII. 
 
 SUR(iKHY OF THE HeAD ^^1 
 
 CHAPTER XVII I. 
 Surgery of the Spine ^^^ 
 
 CHAPTER XIX. 
 
 Surgery of the Face, Mouth, and Neck •>19 
 
 CHAPTER XX. 
 
 Surgery of the Breast, Chest Wall, Lungs, and Diaphragm 
 
 699 
 
CONTENTS IX 
 
 ClIAFTKll XXI. 
 Hkrnia 753 
 
 C'lIAPTKK XXII. 
 
 AuDOMINALSuKCIKKY in GeNEHAL, and LnJUKIES OI' the AI3U0.M1NAI> VlSCEHA 802 
 
 CHAPTER XXIII. 
 Surgery of the Ga.stro-inte.stinal Tract 848 
 
 CHAPTER XXIV. 
 
 Surgery of the Call-uladder, Liver, Pancre.\s, and Spleen 919 
 
 CHAPTER XXV. 
 
 Surgery of the Bladder and Kidneys 958 
 
 CHAPTER XXVI. 
 Venereal Diseases ' . . . 989 
 
 CHAPTER XXVII. 
 
 Surgery' of the Urethra and Prostate 1015 
 
 CHAPTER XXVIII. 
 Surgery' of the Male Genital Org.\ns 1043 
 
 CHAPTER XXIX. 
 
 Surgery of the Female Genitals 1064 
 
SLIllGERV; ITS I'liLNCIPI.ES A.XJ) I'llACTICE. 
 
 The word Surj^ery (old English Chirurgery) is derived from two 
 Greek words, yt'-i' and ^l')'"'", signifying respectively hand and work; 
 as distingnished from the work of the physician, surgery was there- 
 fore formerly confined to such mechanical procedures as were carried 
 out by the surgeon under the direction of the physician. Such was 
 the position of the surgeon in the middle ages; but, since the time of 
 Ambroise Pare (1509-1.190), who is thus justly styled the Father of 
 Modern Surgery, the Science and Art of Surgery have advanced step 
 by step toward such a point of perfection as long since to have entitled 
 them to equal rank with ^Medicine. And though the highest func- 
 tions of surgery still remain mechanical in nature, it is no longer the 
 physician who plans and directs the mechanical treatment, but the 
 surgeon himself who selects the patient, devises the operation, and 
 determines at what stage of the malady surgical measures shall be 
 employed. 
 
 Underlying all disease, and therefore necessary to an understand- 
 ing of disease processes, surgeons encounter a pathological state 
 which constitutes the process by which the bodily tissues react to 
 injury. If the injury be very severe, immediate death of the part 
 may ensue; and there will then be, in that part, no reaction to the 
 injury. At the \ev\ outset of the study of surgery, it is proper to 
 discuss at some length the reaction which takes place when the tissues 
 are injured, because only when the underlying principles of disease 
 and injury ha\'e been thoroughly mastered, can it be hoped to study 
 with profit the special affections which subsequently will be discussed. 
 
 chapter i. 
 l\fla:\imation. 
 
 The process by which the tissues react to an irritant is known as 
 Inflammation. The student must therefore learn what are the usual 
 irritants which produce these changes; he must study the changes 
 themselves, and their results; he must familiarize himself with the 
 subjective and objective symptoms due to these tissue changes; and 
 he must finally learn how to relieve the patient of his suft'ering. It 
 
1 8 IX FLA MM A TION 
 
 therefore becomes necessary to discuss the causes, the pathology, the 
 symptoms, and the treatment of inflammation. 
 
 Causes. — The predisposing causes of inflammation are those which 
 render the patient especially liable to the action of irritants, which 
 are the exciting causes. Any constitutional state, therefore, which 
 lowers the resistance to disease or injury will act as a predisposing 
 cause. Age, especially the extremes of life, influences the develop- 
 ment of inflammation in this way. Occupation and habits also have 
 an undoubted influence, by undermining or by strengthening the con- 
 stitution. Past or present diseases may very seriously modify the 
 patient's resistance to the exciting causes of inflammation. 
 
 In general it may be admitted that the exciting or determining 
 causes of inflammation are either mechanical or chemical, using these 
 terms in their broadest sense, and including in the latter all causes 
 (thermal, electrical, radio-active, infective) which are not distinctly 
 mechanical in their action. But while it is expedient to acknowl- 
 edge that the process of repair which occurs after such mechanical 
 injuries as contusions, fractures, aseptic wounds, and the like is in 
 very fact an inflammatory process, it is nevertheless proper to recog- 
 nize the fact that the vast majority of inflammatory affections are 
 directly due to chemical irritants produced in the tissues by micro- 
 organisms, especially bacteria. Indeed, it is seldom susceptible of 
 satisfactory proof that bacteria are entirely absent in the class of 
 injuries first mentioned; for it is probable that all patients, and even 
 persons in good health (Adami), have somewhere in their system 
 certain bacteria which, being carried by the blood or lymph currents, 
 eventually will reach the region of damaged tissue, and will there be 
 enabled to prosecute their nefarious work to better advantage than 
 where there exists no locus minoris resistentioe . 
 
 Foreign bodies were cited formerly as examples of purely mechani- 
 cal causes of inflammation; but unless it can be proved that the 
 foreign body is aseptic, and that the part of the body where it lodges 
 (eye, skin) is also free from bacteria, it is proper to assume even in 
 such cases that the resulting inflammatory reaction, if noticeable, 
 is due as much to bacteria as to the presence of a foreign body. 
 Indeed, we know that many sterile foreign bodies (ligatures, sutures) 
 constantly remain in the tissues after aseptic operations, and are 
 productive of no manifest inflammatory reaction. Likewise calculi, 
 formed in the internal organs, if sterile themselves, may be productive 
 of only trivial discomfort until bacterial infection occurs in their 
 containing viscus. 
 
 The bacteria which surgeons most frequently encounter as causes 
 of inflammation are the Micrococcus pyogenes (Staphylococcus); 
 Streptococcus pyogenes; Bacillus coli commimis; Gonococcus; 
 Bacillus pyocyaneus; Pneumococcus; Bacillus typhosus; Bacillus 
 tuberculosis; Bacillus tetani; Bacillus mallei; Bacillus anthracis; 
 Bacillus oedematis maligni; Bacillus aerogenes capsulatus, etc. 
 These microorganisms are known as Pathogenic Bacteria, because 
 
PArilOLOGY 19 
 
 they are thcnisolves the causes of (Hsease; tliey take up their abode 
 and thri\e in li\iug tissues, which tliey use as pahuhun. Tliey are 
 to be distinguished from Saprophytic Bacteria, which exist only in 
 dead tissues; these can be rep;arded as causes of disease only in a more 
 or less indirect maimer, because it is necessary that other agents, 
 chiefly the patliogenic bacteria, shall have previously brought about 
 the death of the tissues. 
 
 In addition to bacteria, certain other forms of microorganismal 
 life must be recognized as occasional causes of the inflammatory 
 process in man. Among these are certain animal parasites, certain 
 Yeasts, or Blastomycetes, and certain ^loulds, or IIyi)homycctes. 
 Among the more important of the latter may be mentioned Oidium 
 Albicans, which causes Thrush; the various forms of fungi, which cause 
 the skin lesions of favus, tinea, etc.; and the Ray Fungus, which 
 causes Actinomycosis. 
 
 The chemical substances produced by pathogenic bacteria, as a 
 result of their action upon the tissues, are described by the general 
 name toxiris (Roux and Yersin, 1888); endo-toxins are those substances 
 formed in the bodies of dead or dying bacteria. Both toxins and 
 endo-toxins act as chemical irritants, and it is these products of 
 bacteria, and not the bacteria themselves, w^hich are regarded as 
 causes of inflammation. The products of pathogenic bacteria are 
 albnniinoid in nature; those elaborated by saprophytic bacteria are 
 alkaloidal, and go by the general name ptomains. The action of thermal, 
 electrical, and radio-active agents as causes of inflammation will be 
 discussed under separate sections in other portions of this volume. 
 
 Pathology. — The pathology of the inflammatory process is the same 
 in kind, though varying somewhat in its characteristics, according 
 to the irritant cause, and to the particular tissue aflfected. Certain 
 bacteria produce a reaction so peculiarly characteristic that surgeons 
 have dignified the resulting processes by erecting them into diseases 
 to which special names are applied. Such are Tuberculosis, Syphilis, 
 Anthrax, Glanders, and other affections which are grouped together 
 as the Infectious Granulomas. These diseases therefore are described 
 in a separate chapter (Chapter III); in the present chapter will be 
 described only those changes which are usually understood when the 
 term inflammation is used. Even among the })acteria which cause 
 the changes universally recognized as inflammation, the form of 
 reaction varies considerably, so that it is sometimes possible to assert 
 without microscopical or bacteriological examination that the inflam- 
 mation is due to one variety of bacteria, not to another. It is also 
 sometimes possible for the experienced observer to assert that the 
 same variety of microorganism is the cause of quite divergent types 
 of inflammation in different organs or tissues of the body. 
 
 If one were to watch under the microscope the changes which occur 
 in a part on which an irritant is acting, he would obtain a very accurate 
 idea of the process of inflammation. This may be done in the patho- 
 logical laboratory; but great experience is required properly to inter- 
 
20 
 
 /.VF/..LV.V.4 770.V 
 
 pret what is seen; and for practical purposes it is better to study, at 
 leisure, a series of illustrations of an inflamed area, made at various 
 stages of the process. 
 
 Studyintr first the vascular tiss-ues, it is noted that the capillaries 
 dilate, those which before were too small to allow the entrance of the 
 cellular elements of the blood now increase in diameter, and it is even 
 possible that new vascular channels may be formed. More blood 
 comes to the part, more blood passes through it, and more blood 
 leaves it, than in the normal state. This change is spoken of as active 
 hyperemia {determination, fluxion of blood j, to distinguish it from 
 passive hyperemia or congestion; in this latter state, although there is 
 more blood actually in the part than in the normal state, yet the blood 
 
 ^■%f/^^'"^' M:^ 
 
 Fig. 1. — Subcutaneous tissue some distance above dead part in a case of spreading 
 gangrene. Note stasi-'i, margination, and inigration. Three veins packed with leuko- 
 cytes (I), which are escaping freely. Around the arterj- (below) there are none. Out- 
 side the vessels many larger cells are seen. X 200. (Green.) 
 
 is more or less stagnated in the part, and does not leave it. owing to 
 venous obstruction, which is the prime cause of the congestion. In 
 inflammation, although no cause of venous obstruction exists, the 
 active hyperemia above described soon undergoes a change, so that 
 the picture more nearly resembles that seen in congestion. The 
 blood moves more slowly through the vessels, the blood cells, espe- 
 cially the leukocytes, tend to cling to the vessel walls (margination), 
 and eventually some of the leukocytes escape through spaces between 
 the endothelial cells lining the capillaries by a process known as migra- 
 tion (.1. F. Cohnheim. ISfi?). In some cases of severe inflammation 
 the erythrocytes may be forced out of the vessels as well ((liapefh'sis). 
 In the case of the leukocytes, however, the process is active (migration), 
 and is not a mere matter of filtration by the vis a tergo. According 
 
p.\Tiioj/)(;y 21 
 
 to recent observations it seems prohiihle that the en throcytes escape 
 from the vesssels in tlie wake of the knikocytes, heiiifj:; sncked out by 
 the currents i)ro(hice<l in the bhiod-phisma by the migration of the 
 wliite bh)o(l cells. In the process of migration of the Icnkocytes, 
 first a portion of the cytoplasm, projected as a pseudojjod, emerges 
 through the vascular wall; then more of the cell body follows; and 
 finally the portion still remaining within the bloodvessel flows out into 
 that portion which has already migrated. It has been noted by Coun- 
 cilman that the portion of the cell to migrate first always contains 
 the nucleus; and it has been suggested by Adami and others that 
 there exists some relationship between "the labile, broken-up char- 
 acter" of the nucleus of i)()lymorphonuclear leukocytes (perhai)s 
 karyokinetic figures) and their function of migration through the 
 vessel walls. 
 
 It is further evident that some of the plasma of the blood has 
 escaped from the vascular channels and is infiltrating the perivas- 
 cular connecti\e tissue; for the connective tissue cells may be seen 
 to swell up and become engorged with foreign fluid. This fluid exudate, 
 however, is not unaltered blood-plasma; it contains a higher per- 
 centage of proteids, and its specific gravity is higher; it also coagu- 
 lates more quickly. Moreover, as will be pointed out presently, it 
 is extremely rich in bactericidal and antitoxic substances. The 
 increase of serum in an inflamed part is frequently very apparent 
 macroscopically when incisions are made to relieve tension, especially 
 in the loose subcutaneous tissues; and when inflammation occurs on 
 free surfaces, as the peritoneum or the mucous membranes, or just 
 beneath the cuticle, as in blisters, the outpouring of this fluid exudate 
 is very evident. Its quantity and quality are also influenced by the 
 variety of bacteria present. 
 
 Looking a little later at the inflamed area, the first thing to be noted 
 is that there has accumulated in the perivascular tissues an immense 
 aggregation of small round cells. These cells accumulate in response 
 to an influence of chemical nature exerted upon them by the bacteria 
 or other irritant; this influence is known as chemotactic action 
 (Pfeffer, 1888^, and because the cells are drawn toward the acting 
 body, we speak of it as positive chemotaxis, in contradistinction to 
 negative chemotaxis, which term is used to describe the repelling 
 action of certain cells or microorganisms. It is now regarded as 
 certain that the endothelial cells lining the bloodvessel walls take an 
 active part in the production of this round-cell infiltration, under 
 the influence of the positive chemotactic action of the irritant. These 
 endothelial cells may be seen to swell up and bulge into the lumen of 
 the vessels. In this manner they seem to become possessed of agglu- 
 tinative characteristics, which aid in slowing the blood stream and 
 in producing the margination of the leukocytes already described. 
 It is not impossible that, by their change of form, these endothelial 
 
 1 According to the late Prof. Ashhurst, the germ of the idea of chemotaxis is 
 to be found in the writings of Haller. 
 
22 INFLAMMATION 
 
 cells may render the vessel walls more readily permeable to the 
 leukocytes. 
 
 The origin of this vast aggregation of round cells next engages 
 our attention. By reference to our previous study of the changes 
 in the vascular tissues, it is quite evident that large numbers of the 
 round cells found in the inflamed tissues have been derived from the 
 leukocytes of the blood by migration. But even in tissues without 
 bloodvessels, such as the cornea, a similar aggregation of cells occurs 
 in inflammation; so that it is manifest that much of the round-cell 
 infiltration is derived from other sources than the bloodvessels. 
 These other sources are the lymph cells, which exist in the perivas- 
 cular tissues within the lymph spaces and lymph capillaries; and the 
 fixed connective tissue cells, which as the result of a retrograde 
 metamorphosis come again to resemble the less highly developed 
 lymphocytes (Strieker, 1881). Strieker also believed that the inter- 
 cellular connective tissues could, under the influence of the inflam- 
 matory process, revert again to the embryonal cells from which they 
 were first derived. Whether Strieker's views should be accepted or 
 not, is still perhaps open to discussion; but pathologists think it miich 
 more certain at present that a large proportion of the round-cell aggre- 
 gation is derived from the endothelial cells lining the lymph spaces 
 of the perivascular tissues. Indeed, according to some modern his- 
 tologists (Adami) there are no such structures as those formerh' 
 described as the fixed connective tissue cells; for they hold that 
 the only cells found in the tissues, besides the lymphocytes and the 
 wandering leukocytes, are these very endothelial cells, and that the 
 spaces (hypothetical or real) between them are to be regarded as 
 lymph channels. 
 
 In regard to the origin of the lymphocytes, Warthin (1906) follows 
 Ribbert in teaching that they are in great part derived from rudi- 
 mentary h'mph nodes scattered through the tissues. 
 
 The great number of cells which infiltrate the tissues at this stage 
 of the inflammatory process, must not be regarded as a mere aggre- 
 gation of previously existing cells. It is probable that all the cells 
 multiply by continual division and subdivision under the stimulus of 
 inflammation, and that the number of cells in the part is thus actually 
 as well as relatively increased. This fact is evident from the mitoses 
 which may be seen in an inflamed area under the microscope. 
 
 Thus it is that we find three main types of cells composing this 
 cellular infiltrate: (1) the emigrated leukocytes, which are chiefly poly- 
 morphonuclear neutrophiles; in the early stages of inflammation there 
 may be a relative increase of eosinophile cells; (2) the lymphocytes, 
 which seldom accumulate in great numbers until the inflammation 
 has existed for some days; and (3) cells derived from the fixed con- 
 nective tissue cells or from the endothelial cells, or from both. These 
 last named cells are conveniently classified by Adami as fibroblasts 
 and polyblasts, the latter term, first employed by ^laximow, being 
 intended to signify that they are immature types of various different 
 
PATHOLOCY 23 
 
 kinds of fully formed cells; while the iiaiiie fihrohliist is still used to 
 describe that form of iuuuature coimective tissue cell on wiiich the; 
 subseciuent process of repair chiefly depends. 
 
 When we come next to inquire into the object of this round-cell 
 infiltration, we learn by observation that a veritable warfare is going 
 on between the bacteria and these cells. We observe, for instance, 
 that many of the cells (leukocytes and endothelial cells in particular) 
 have, as it were, swallowed some of the bacteria; for we see such 
 cells with one, two, three, or more bacteria in their interior. We 
 may infer that some of the bacteria are being killed, both from the 
 gradual diminution in their total number, as well as because the indi- 
 vidual bacteria no longer stain so well as at first; and we also per- 
 ceive that many of the bod}' cells succumb, because their nuclei swell 
 up, their protoplasm becomes cloudy, they fail to stain, and finally 
 disintegrate and disappear, while the triumphant bacteria attack 
 other cells. This process, by which the cells devour the bacteria, is 
 known as phagocytosis (Metchnikoft', 1893), and the cells which thus 
 act are called phagocytes. 
 
 Moreover, in addition to the defence thus provided by the cellular 
 elements called into action by the irritants causing inflammation, 
 there exist in the body fluids certain substances (anti-bodies) which 
 act as very important aids in the defence. In the normal blood- 
 plasma exist certain chemical substances termed opsonins (Wright 
 and Douglas, 1908), because they act as caterers for the phagocytes, 
 by preparing the bacteria for destruction. Thus it has been found 
 that though white blood cells are active phagocytes while still sur- 
 rounded by blood plasma, they are absolutely indifferent to bacteria 
 if deprived of plasma. In the fluid exudate which is produced during 
 the inflammatory process there are also chemical substances, known 
 as bacteriolysins (Nuttall, 1888), which are extremely destructive to 
 these causes of inflammation; these bacteriolysins are classified as 
 alexins (Buchner, 1890), which destroy the bacteria, and antitoxins 
 (Behring, 1890), which neutralize the bacterial toxins. It is probable 
 that they are both produced by disintegration of leukocytes. These 
 inflammatory exudates have a specific gravity of 1018 or higher, and 
 contain at least 4 per cent, of albumin; they may be distinguished 
 thus from exudates due to venous stasis, and to those caused by 
 hydremic conditions, the fluid in the latter instances having a much 
 lower specific gravity, and containing less albumin. 
 
 The process of inflammation, as thus far described, comprises 
 clinically what has been termed the first stage of inflammation, or the 
 stage of temporary hypertrophy. If at this stage of the process the 
 invading microbes are vanquished, the parts return to their normal 
 condition (resolution) without passing through the subsequent stages 
 of inflammation. If, on the other hand, the strife is prolonged, the 
 fluid exudate and the cellular infiltrate increase in quantity, and the 
 product of the second stage of inflammation, known as inflammatory 
 lymph, is formed {lymphization, lymphogenesis .) 
 
24 INFLAMMATION 
 
 Inflroiniuitori/ h/iiiph (Hunter, 1794) is a semi-solid, gelatinous 
 substance, grayish white or slightly yellowish in tint. Though found 
 at least for a .short time in every case of inflammation which extends 
 beyond the first stage, it is best observed in peritoneal infections, 
 and in iritis, in both of which instances the inflammatory exudate 
 occurs on a free surface. The false membrane of diphtheritic inflam- 
 mation is another instance of lymph formation. Lymph owes its 
 semi-solid, plastic character to the fibrin it contains. The cellular 
 elements are not usually very numerous in the early stages of its 
 formation, when the exudate is still "serous," but as the quantity of 
 cells increases, fibrin ferment is formed by the destruction of some of 
 their number, and this fibrin ferment acting upon the fibrinogen and 
 certain calcium salts already present in the exudate, eventually forms 
 fibrin. Certain infectious agents call forth an abundant exudation 
 of inflammatory lymph; while others are characterized rather by the 
 excessive round-cell infiltration produced. For example, peritonitis 
 due to the typhoid bacillus is characterized by profuse serous 
 exudate; when caused by the streptococcus, or the colon bacullus, 
 the exudate contains a much larger proportion of cellular elements, 
 and therefore more closely resembles typical inflammatory lymph. 
 Moreover, fluid exudation is more abundant on surfaces, and in 
 the loosely built cellular tissues, than in denser structures such as 
 bone. 
 
 Lymph serves a useful purpose in more ways than one, for not only 
 does it enmesh the microorganisms and thus prevent their diffusion 
 in the tissues, but it also actively destroys them and their products 
 by means of the bacteriolysins already described. It also prevents 
 absorption of the microorganisms by protecting denuded endothelial 
 surfaces. It is, therefore, to be regarded as a valuable defence of the 
 body against infection, and not as a noxious product to be removed 
 by the surgeon. 
 
 Lymph may be absorbed, may become organized, may become 
 converted into j^u-s, or may undergo other forms of degeneration 
 (caseous, calcareous, etc.). If the lymph is absorbed, its cellular 
 elements pass away again into the neighboring blood and lymph 
 streams, or remain as fibroblasts to produce new connective tissue in 
 the area of inflammation. Where the process of inflammation is 
 attended by coincident j^roductive and absorptive changes, in approxi- 
 mately equal degree, the condition is described as interstitial absorp- 
 tion. This condition is seen particularly in some forms of osteitis. 
 In the process of organization, which will be described more particu- 
 larly in the section on Repair (p. 29), these fibroblasts pass through 
 various stages until adult connective tissue is formed. It is very- 
 unusual, however, for complete regeneration {restitutio ad integrum) 
 to take place; almost always some of the cells remain in an immature 
 state, while others are converted into scar tissue. In certain specialized 
 forms of inflammation, lymph undergoes various forms of degeneration, 
 as the caseous or calcareous, in tuberculosis; but in all cases in which 
 
iwrnoLOGY 
 
 the inflammatory process eoMtinues, 1\ iiipli is cvciituaily converted 
 into jms (siipjuintiioii, pi/ofinirsi.s). 
 
 Pus may be defined as the pnxhict of the third sta^e of inflannna- 
 tion. By giving a broad definition such as this, we are i)ermitted. 
 
 6-V--V : 
 
 '<r'? ■ 
 
 Fig. 2.— Miliai^- abscess in a case of septic embolism of the kidney: a, leukocytes 
 advancing toward and surrounding b, a mass of cocci, in whose "^^g^borhood alU^^^^^ 
 of a structure has disappeared; c, renal opithehum too damaged b^ ^^f.^XrvS^^^^ 
 to take the stain; d. kidney tissue staimng normally ;e. vein from which leukocytes are 
 making their way to the commencing abscess. X lUU. (Creen.j 
 
 as is pathologically proper, to include imder the term pus, not only 
 the healthy, laudable pus ^vhich the older surgeons ^ve^e so delighted 
 to behold,' as an expression of adequate reaction on the part of the 
 patient's tissues; but ^ve may also embrace, under the term pus, the 
 
26 IXFLAMMATIOX 
 
 products of tuberculous, syphilitic, and siniilar processes which, as 
 A(himi points out, "are identical witii the tissue dissolution that 
 occurs in acute abscess." 
 
 Pus, when examined under the microscope, is seen to be composed 
 of cells and of granular detritus, more or less homogeneous in char- 
 acter, floating in a fluid known as the Liquor Puris. Bacteria usually 
 are present also. The cells are the leukocytes, lymphocytes, and con- 
 nective tissue cells, which formerly constituted the round-cell infiltra- 
 tion of the earlier stages of the inflammatory process; but which have 
 been killed by the bacterial toxins, etc. The granular detritus consists 
 of the remains of the cellular elements and intercellular substance 
 of lymph, which have been disintegrated by the ferments (peptones, 
 etc.) generated during the warfare between the bacteria and their 
 toxins with the body cells and their bacteriolysins. The Liquor 
 Puris is the slightly altered fluid exudate already described. In other 
 words, pus has been produced from lymph by a species of liquefaction 
 necrosis. 
 
 If pus is completely circumscribed by the body tissues it consti- 
 tutes an abscess. If it is formed on the surface of a part it is said to be 
 constantly "discharged." If neither formed on a surface nor well 
 circumscribed, but rather diffusely infiltrated among the body tissues, 
 the pus is said to form a phlegmon; and the inflammation is said to be 
 phlegmonous in type. In any case, there is a certain surrounding area 
 where the strife between the body tissues and the invading micro- 
 organisms still continues. This area, when surrounding an abscess, 
 was formerly spoken of as a pyogenic membrane, because it was believed 
 that pus was secreted in the same way as the secretion of a gland is 
 produced. If the body tissues succeed in holding their own, and the 
 invasion comes to a halt, then there is formed in the area surrounding 
 the abscess what is known as granulation tissue; if, on the other hand, 
 the body tissues continue to be destroyed by the bacteria and their 
 toxins, then the process is described as ulceration, provided the change 
 occurs on a free surface (as on the skin after burns, or in the intes- 
 tines in typhoid fever, etc.). For although, from a pathological 
 point of view, the process which occurs at the so-called pyogenic 
 membrane of an abscess is identical with that which occurs on a free 
 surface on which pus is being produced by ulceration, yet the latter 
 term is never applied to the former process; we merely say that the 
 abscess continues to increase in size. 
 
 Pus which exists in the form of an abscess may perhaps be absorbed, 
 under exceptional circumstances, if the amount of pus be very small. 
 When this occurs, the granulation tissue extends into the puriform 
 mass, the debris is taken up by phagocytes, and is gradually carried 
 away in the blood and lymph channels. In other cases, where the 
 amount of pus is small, and where the abscess is deeply situated, 
 the pus may become encapsulated, by the deposition in the surrounding 
 granulation tissue of lime salts, or even by the development of 
 extremely dense fibrous tissue. In such cases the contained pus 
 
s('ri'rh'.\Ti()\ wininrr hacteria 27 
 
 •gradually l)e('(nnes sterile, hi all cases, however, in whieh tliere is 
 any ajjpreeiable amount of pus jjresent, the pus tends to seek an exit 
 for itself in the direction of least resistance. When the pus has once 
 discharj^'cd itself, the former abscess cavity will j^radually assume the 
 character of an idccraiituj, or rather of a (/nutuldfing surface, and the 
 process of repair will be the same in both instances — that of an 
 evacuated abscess and that of an ulcer. 
 
 Role of the Nervous System in Inflammation, in the account of 
 infianunation so far fjiven, no mention has been made of any part 
 played by the nervous system. This is so, because it plays only a 
 very insignificant part in this process. Experiments have proved that 
 even when the entire ner\ous supply of a part has been cut off, the 
 phenomena of reaction to injury, as described above, occur without 
 api)reciable difference; from which fact it may be assumed either that 
 the local vascular system is endowed with a nervous mechanism of 
 its own (which does not appear to have been proved), or that the 
 vascular changes seen in inflamed areas take place without the inter- 
 position of nervous action. According to Warthin (19()Gj, however, 
 it has been demonstrated experimentally that removal of the vaso- 
 constrictor influence accelerates, while removal of the vaso-dilator 
 influence retards inflammatory reaction. Too little is known of the 
 ])seudo-inflammatory changes which occur in the various neuropathies 
 for pathologists to speak with authority about them. It is certain, 
 nevertheless, that under certain circumstances lesions of the nervous 
 system may very greatly influence the course of inflammation, as 
 seen in the case of bed-sores in spinal diseases, and in certain so-called 
 trophic lesions. 
 
 Extension of Inflammation. — This occurs (1) by continuity, as when 
 l)ronchitis extends into the pulmonary tissue, causing pneumonia; 
 or when urethritis extends into the bladder, producing cystitis; (2) 
 l)y contiguity, as when pneumonic inflammation extends to the pleura, 
 causing pleurisy; or when peritonitis developes from appendicitis; 
 (3) by the lymphatics, as when a felon in the finger is followed by 
 lymphangeitis and epitrochlear or axillary lymphadenitis; or (4) by 
 the blood stream, as in certain of the exanthemata, and in metastatic 
 inflammations. 
 
 Terminations of Inflammation. — Inflammation may terminate in two 
 ways: (1) by resolution, a gradual return of the part to health; (2) 
 by death of the patient. It is sometimes said that inflammation may 
 terminate in the local death of the part aftected ; but as the surrounding 
 parts will still be the seat of the inflammatory process, or of repair, 
 until either death or recovery terminates the disease, it is more logical 
 to recognize this fact in our definition. The manifestations of the 
 local death of a part (sloughing, mortification, gangrene) will be con- 
 sidered in Chapter II. 
 
 Suppuration without Bacteria. — In what has been said above, it is 
 assumed that the suppuration described has been caused by bacteria; 
 and in the immense majority of instances this is the case. But it should 
 
28 
 
 INFLAMMATION 
 
 not be forgottou that other cheiiiical forms of irritation, as well j)er- 
 haps as eertaiii meehaiiieal irritants, may produce pus, if their action 
 is sufficiently virulent or i)rolonf^e(l. Hypodermic injections of tur- 
 pentine, mercury, croton oil, or other sterile substances, may cause 
 all the usual phenomena of inflammation, and this may proceed so 
 far that a fluid will be formed, which will l)e found to consist of the 
 disintegrated products of tissue metabolism, and which will be indis- 
 tinguishable from pus as described above, except for the facts that no 
 bacteria will be present, and no phagocytosis will be evident. It is 
 (luite apparent, nevertheless, that, even in such cases, the round-cell 
 infiltration, which succeeds to the early hyperemia and congestion, 
 has been producefl by chemotactic action on the part of the irritant, 
 and that the accumulated cells and tissue fluids in the process of 
 their reaction are converted into substances which if not technically 
 bacteriolysins, are some other form of antibodies none the less useful 
 for the defence of the organism. 
 
 Nor should it be assumed, on the other hand, in every case in which 
 inflammation is produced by bacteria, that the process necessarily 
 will extend to the stage of suppuration. In very many cases in which 
 bacteria are present, the reaction on the part of the body tissues is 
 sufficient to repel or to conquer the foe before pus is formed; but it 
 is much more usual for this happy termination of the process to occur 
 when the causes of the inflammatory reaction are sterile. This is 
 well seen in the usual course pursued by clean wounds. 
 
 Fig. 3.— Staphylococci in pus. X 1000. 
 (Friinkel and Pfciffer.) 
 
 Fig. 4.— Streptococci in pus. X 1000. 
 (Frankol and Pfeiffer.) 
 
 Pyogenic Bacteria. — Certain microorganisms are habitually pyo- 
 genic; certain others produce pus only under special circumstances; 
 while a few varieties have never been known to cause sui)puration. 
 It is, therefore, possible to classify pathogenic bacteria in the follow- 
 ing manner: (1) Microdrganisms characteristically leading to pus and 
 abscess formation — Staphylococcus, Streptococcus pyogenes, Bacillus 
 
RKl'MR _ 29 
 
 antliracis. Of tlioso, tlio \arieti(\s of tlic stapliylocoociis (Iciioted hy 
 tlie suffixes aureus, (tlbus, and cltreus, and jijciu'rically included under 
 tlie term IMiorococcus pyogenes, are those which are especially asso- 
 ciated with acute, well-locali/ed abscesses; they are found in felons, 
 furuncles, carhinicles, acne, some cases of empyema, and certain 
 forms of periosteitis, osteomyelitis, etc. The streptococcus, on the 
 other hand, is associated with spreadin<ji: infections, such as diffuse 
 cellulitis, erysipelas. lymphaiifi;eitis; certain forms of osteomyelitis, 
 peritonitis, etc. The Bacillus antliracis is the cause of a specific 
 disease, which will he describeil in Chapter 111. (2) Those causing 
 suppuration ouly under exceptional circumstances — Pneumococcus, 
 Bacillus typhosus, Bacillus coli communis, Bacillus pyocyaneus, 
 (lonococcus, Jiacillus tuberculosis, etc. (8) Those which are never 
 known to cause the j'orination of pus — as Bacillus tetani. 
 
 Pathological Summary. — The first action of an irritant when intro- 
 duced into the tissues is chemotactic in nature; this influence extends, 
 without the aid of the nervous system, to the endothelial aiKl other 
 connective tissue cells lying in the perivascular tissues; it also extends 
 to the cells of the vascular endothelium, and even to the white cells 
 of the circulating blood. The effect of this positive chemotaxis is to 
 slow the blood current and to cause the endothelial cells of the blood- 
 vessels to acquire agglutinative properties. As a result, hyperemia, 
 and later congestion is produced; margi nation, followed by migration 
 of leukocytes, occurs; exceptionally diapedesis of the red blood cells 
 also is present. Round-cell infiltration is produced in this way, as 
 well as by the multi])lication of those cells already present in the 
 inflamed part. This constitutes the first stage of infiammation, that 
 of Temporary Hypertrophy. The warring hosts have been assembled 
 and the battle between the invading microorganisms and the phago- 
 cytes is next begun; the fluid exudate aids the cells in the fight by 
 means of its bacteriolysins. Lymph is thus produced, constituting 
 the second stage of inflammation. Owdng to the progressive destruc- 
 tion of leukocytes and other cells, ferments are produced, which 
 liquefy the lymph, converting it into pus; thus by pyogenesis, the 
 third and last stage of infiommation is reached. In the surrounding 
 tissues progressive destruction {ulceration) continues, or gradual repair 
 {granulation) terminates the process. 
 
 Repair. — It has been pointed out (p. 28) that the inflammatory 
 process may be terminated at any stage of its course as a result of the 
 defensive powers of the organism overcoming the invasion of the 
 irritant which was the primary cause of the inflammation. Speaking 
 generally, we may recognize three more or less distinct ways in which 
 repair occurs, corresponding to the three stages of inflammation 
 described. 
 
 1. If the process of inflammation is arrested during the stage of 
 temporary hypertrophy, before any exudate has been formed, the 
 migrated leukocytes and other phagocytes, having destroyer! the bac- 
 teria, and being no longer attracted by the chemotactic influence of 
 
30 INFLAMMATION 
 
 the imaders, resume their normal functions and return to their usual 
 spheres; the white blood cells re-enter the capillaries, the lymph cells 
 swim away in the lymph stream, and the site of former inflammation 
 can no longer be distinguished from the surrounding tissues; it is said 
 to have undergone regeneration, complete repair, restitutio ad integrum. 
 
 2. If the process of inflammation is arrested during the stage of 
 lymph formation, complete regeneration cannot take place, because 
 the tissues are not capable of removing completely the results of the 
 warfare betAveen the irritant and themselves. Some of the cellular 
 elements may pass away again in the blood and lymph streams, but 
 almost without exception a goodly number will remain in the pre- 
 viously inflamed part, will become converted into fibroblasts, and 
 eventually will form scar-tissue. It does not seem to be certainly 
 known whether leukocytes ^an become converted into fibroblasts; 
 but there is no doubt that most of the fibroblasts are produced from 
 endothelial or fixed connective tissue cells. Fibroblasts are elongated, 
 caudate, or spindle-shaped cells, occasionally stellate in form. 
 
 The area of inflammatory exudation becomes vascularized by the 
 out-growth of capillaries from the surrounding bloodvessels. These 
 new capillaries grow as solid sprouts; and these solid processes, grow- 
 ing out into the exudate of inflammatory lymph, either meet other 
 similar out-growths, or become attached to a neighboring capillary, 
 thus forming more or less distinct loops; these loops subsequently 
 become hollowed out, and the channels so formed are filled by blood 
 from the surrounding capillaries. As the process of repair goes on, 
 the fibroblasts become more and more fibrous in character " until the 
 cell is represented by a meagre, attenuated nucleus, with but a trace 
 of cytoplasm, lying surrounded by fibrils — white connective tissne." 
 (Adami.) The conversion of the fibroblasts into white connective 
 tissue and the invasion of the inflammatory exudate by the capillary 
 loops go on hand in hand; the tissue thus formed is known as granu- 
 lation tissne; and when the process occurs on a free surface the capil- 
 lary loops form the so-called granulations. The granulation tissue is 
 at first highly vascular and red; as the more fully de\-eloped scar- 
 tissue is formed, granulation is succeeded by cicatrization, and the 
 capillaries are squeezed out of existence as the process of contraction 
 in the scar-tissue continues. Thus a scar which at first is red and 
 angry in appearance, eventually may become white, glistening, and 
 depressed below the surrounding tissues. The area of previous inflam- 
 mation, which during the height of the inflammatory process Avas 
 swollen and tense, thus finally comes to occupy less space than in 
 health. 
 
 3. If the process of inflammation has progressed to the stage of 
 suppuration, then in almost all cases it is necessary for the pus to be 
 discharged by the rupture of the abscess before rapair can occur. 
 It is extremely unusual for pus to be absorbed or for scar-tissu6 to be 
 formed unless the abscess has first been converted into an ulcer. 
 Repair in this instance, therefore, is best studied as it occurs on a 
 
syMPTO}rs 31 
 
 free surface, and is tlie same as tliat wliich occurs in the healing of 
 an ulcer (p. 53). 
 
 / 
 
 
 V 
 
 -- <r 
 
 Fig. 5. — Fibroblasts and granulation tissue. Section of a cutaneous granulation: 
 V v', new-formed capillaries sprouting from depth of granulation and accompanied by 
 connective tissue cells (c) and leukocytes (/). A layer of fibrin (/) covers the surface 
 of the granulation. Between the superficial layers of the fibrin are seen large connec- 
 tive tissue cells (d') springing from the granulation (rf). X 300. (Cornil and Ranvier.) 
 
 Symptoms. — The symptoms of inflammation are local and general 
 (or constitutional). x\mong the latter are the usual signs of fever, 
 attended frequenth' b}' quickening of the pulse and respiration rate; 
 headache, flushing of the face, brightening or injection of the eyes, 
 and perhaps delirium at night; anorexia, with furred tongue, and 
 sometimes nausea; dry, hot skin; thirst; usually the bowels are 
 constipated, and the urine high colored and lessened in quantity. 
 Under constitutional symptoms it may also be proper to include 
 leukocytosis, an increase in the number of leukocytes present in the 
 circulating blood. This leukocytosis is present in almost all acute 
 inflammations; it is called forth by the chemotactic powers of the 
 irritant, whose diifusible toxins, when they obtain admission to the 
 circulating blood, are carried to the bone marrow and other portions 
 of the body whence leukocytes are derived, and thus stimulate the 
 production of leukocytes. In a few diseases, not usually classified 
 as inflammations, the influence of negative chemotaxis is manifested 
 in the diminution of the number of circulating leukocytes ijiypo- 
 leukocytosis, leukopenia). Among such diseases typhoid fever and 
 tuberculosis are the most important. What were formerly called 
 critical discharges may occur either at the approach of convalescence, 
 
32 INFLAMMATION 
 
 or upon an unfavorable change in the patient's general condition. 
 These discharges are described as diarrhea, diuresis, profuse sweating, 
 and sometimes hemorrhages from the mucous membranes. Their 
 significance, as well as the probable causes and the pathology of 
 inflammatory fever, will be considered in Chapter II. When the 
 inflammation is slight, constitutional symptoms may be trivial or 
 entirely absent; when occurring in robust, healthy indi\iduals, the 
 sthenic type of fever is seen; when in the weak and debilitated, or, 
 when the inflammation is overwhelming, e^•en in the strong, a typhoid 
 (asthenic, adynamic) type of fever will result. 
 
 The local symptoms of inflammation have been described from the 
 time of Celsus under the terms (1) Rubor, or redness; (2) Tumor, or 
 swelling; (3) Valor, or heat; and (4) Dolor, or pain; while to these 
 classical symptoms has been added that of (5) Functio Lcpsa (modifi- 
 cation of function) ; and again a sixth symptom (6) Modification of 
 nutrition. 
 
 One or more of these local symptoms may be present without the 
 disease constituting inflammation; it may be impossible to elicit 
 evidences of one or more of these symptoms, even when inflammation 
 is present. Friction of the skin may produce a temporary hyperemia, 
 accompanied by redness and heat, without true inflammation being 
 present; the erectile tissues furnish another example where the' pres- 
 ence of one or two symptoms alone is not sufficient to qualify the 
 affection as inflammation. On the other hand, it will be impossible 
 in many deep-seated inflammations (meningitis, pleurisy, etc.) to 
 detect redness, and sometimes impossible to demonstrate swelling, 
 even though no doubt can exist that inflammation is actually present. 
 Some of these local symptoms are more manifest in certain tissues, 
 organs or localities, than in others. Thus conjunctivitis, periosteitis, 
 orchitis, are especially painful; cellulitis is preeminently characterized 
 by swelling; alteration of function is more evident the more highly 
 specialized the tissue or organ affected (compare iritis with tonsillitis; 
 neuritis with dermatitis, etc.); while in the cornea and in cartilage 
 alterations of nutrition may be the only demonstrable change. 
 
 Redness is nearly universally present in superficial inflammations. 
 It is primarily due to the hyperemia and congestion of the inflamed 
 part. Early in the course of the disease the redness is bright, flaming, 
 intense, as in erysipelas; later it may become bluish or almost purple, 
 as suppuration or gangrene impends. It is not sharply outlined in 
 ordinary forms of inflammation, but blends away in the surrounding 
 tissues so that it is often impossible to define its exact limits. The 
 redness due to inflammation disappears when the finger is pressed 
 upon the inflamed spot. The rapidity with which the redness returns 
 after the removal of pressure gives a fair idea of the activity of the 
 circulation; if suppuration or gangrene is threatening the circulation 
 is sluggish. It should not be forgotten that a sluggish circulation may 
 be due to organic disease of the heart, and that this will modify the 
 local manifestations of inflammation even in an early stage. 
 
SYMI'TOMS 33 
 
 Snrlling is due to the hyperemia, to the round-eell infiltrate, and 
 to the Hiiid exudate charaeteristie of inflaniniation. Thus tissues 
 where exudation is profuse (eyelid, scrotum, and subcutaneous tissues 
 generally) show more alteration of form than do such structures as 
 hone or cartihij,'e. Blehs frequently form in the skin as the result of 
 effusion of serum beneath the epidermis; this is seen especially in burns 
 and severe contusions, such as those accompanying fractures or dis- 
 locations. Swelling is beneficial in so far as it tends to deplete the 
 overloaded capillaries; it may be harmful by its tendency eventually 
 to block the circulation and thus favor sloughing or gangrene. It 
 may endanger life by occluding mucous channels — such as the glottis, 
 the bile ducts, the appendix; or by compressing the urethra when 
 the swelling occurs in the perineum. The swelling of the early stages 
 of inflammation is tense, and rather elastic to the touch; later it 
 becomes dense and brawny if due to exudate which is coagulable, 
 or edematous and soft if due to non-coagulable effusion. When an 
 inflamed area begins to "pit on pressure," it is often indicative of the 
 presence of pus. 
 
 Heat in an inflamed part usually is appreciable to the hand, when 
 compared with a neighboring or similar part of the patient's body 
 which is not inflamed. In artliritis the affected joint feels hot, while 
 the corresjjonding joint does not. Local heat is doubtless produced 
 in large part by the numerous chemical reactions constantly occurring 
 in the, inflamed area. The toxins, bacteriolysins, ferments, etc., are 
 all of them produced by forms of biochemical activity which thus far 
 are little understood. The mere hyperemia of the part is not suffi- 
 cient to account for the heat present. Yet the local temperature is 
 rarely if ever higher than that of the circulating blood; but it is rela- 
 tively higher than is that of surrounding parts, because there is more 
 blood in the inflamed part, and especially near the surface of the 
 inflamed part, than in surrounding non-inflamed parts; moreover the 
 temperature of the circulating blood may be higher than normal 
 (inflammatory fever), but its abnormal heat is derived from the local 
 changes, not the local heat from a primary increase in the temperature 
 of the blood. The local heat is greatest at the height of the inflam- 
 mation; as the disease progresses the local temperature falls, and when 
 suppuration occurs it is no longer above that of surrounding parts. 
 In the case of gangrene, the temperature of the mortified part naturally 
 becomes subnormal. 
 
 Pain due to the inflammatory process is caused by tension, from cel- 
 lular infiltration and fluid exudation, producing pressure on the terminal 
 nerve fibres of the part. The pain is much less in tissues which admit 
 of much swelling than in fibrous tissues (felon) or bone (periosteitis) ; 
 and it may be relieved In- allowing the escape of the eft'usion through 
 incisions. Inflammation in a part devoid of sensory nerves is not 
 attended by pain. Referred pain is to be explained on anatomical 
 grounds, and is due either to pressure on a ner\e trunk, causing pain 
 in its terminal fibres fas in the case of pain in the knee due to pressure 
 
34 INFLAMMATION 
 
 on the obturator nerve at the hip) ; or to overstimulation of a nerve 
 causing an overflow of painful sensations into neighboring nerves 
 derived from the same spinal segment: thus gall-bladder disease may 
 cause pain in the shoulder through the spinal nerves derived from the 
 same segment as that from which the pneumogastric takes its origin; 
 pain in the testicle follows disease of the kidney or ureter; inflam- 
 mation of the neck of the bladder is accompanied by pain in the head 
 of the penis; pleurisy may cause cutaneous hyperalgesia of the abdo- 
 men. The pain felt in an inflamed part varies with the tissue affected : 
 in the skin (insect bites, etc.) or mucous membranes (conjunctivitis, 
 hemorrhoids, etc.) it is manifested as an itching or scalding sensation; 
 in serous and synovial cavities it is felt as a lancinating or stabbing 
 pain (peritonitis, pleurisy, synovitis); in fibrous tissues it is dull, 
 aching, or boring (periosteitis, etc.). Pain usually is greatest during 
 the height of inflammation; if the nervous structures are poisoned 
 by toxins, the pain may be slight ; sudden cessation of pain frequently 
 is indicative of gangrene (appendicitis, strangulated hernia). At the 
 approach of suppuration, the pain assumes a throbbing character: 
 mortification is frequently announced by a burning pain. 
 
 Tenderness on iiressure is an important modification of the sensa- 
 tion of pain, and may persist when pain has been lost through gan- 
 grene of the inflamed part. Thus even when the spontaneous pain 
 of appendicitis has ceased on the occurrence of gangrene, tenderness 
 may still persist in the surrounding area of the peritoneum. If pain 
 is present in a part without local tenderness, the pain is referred pain, 
 and the seat of inflammation is elsewhere. I have never seen both 
 pain and tenderness present locally in an uninflamed part, unless the 
 tenderness w^as a mere cutaneous hyperalgesia. ]\Iistaking the latter 
 once for a sign of local disease, I removed a normal appendix vermi- 
 formis from a youth who twenty-four hours later developed symptoms 
 of pleuropneumonia. 
 
 Muscular rigidity is due to voluntary or involuntary contraction 
 of the muscles governing the movements of, or protecting an inflamed 
 part. Involuntary contraction is due to the impulse being referred 
 to motor instead of sensory nerves, as is the case in referred pain. 
 
 Impaired function is more noticeable the more highly developed 
 the inflamed structures. It is an old maxim that in inflammation the 
 first functional change is always in the direction of excess. Parts which 
 possess normally very little sensation may become acutely painful; 
 glandular structures produce an abundant, though disordered secre- 
 tion; muscular structures contract irregularly and spasmodically, 
 as in fractured limbs, and in inflammation of the hollow viscera 
 (appendix, stomach, gall-bladder, urinary bladder, etc.). The special 
 senses are even more affected: scintillations of light and photo- 
 phobia attend inflammatory affections of the eye; tinnitus aurium 
 is annoying in certain diseases of the ear; perversions of taste, of 
 smell, etc., are common in affections of the tongue and nose. At a 
 later stage of inflammation the function of a part, instead of being 
 
TREATMENT OF INFLAMMATION 35 
 
 stimiilated, is depressed or altogether abolislicd: during the height of 
 nephritis, the urine is suppressed, and when the secretion is restorecl 
 its nature may he markedly and i)ermanently altered. 
 
 Modification of Nuirition. — The temporary hypertrophy seen in the 
 earlier stages may never be recovered from; scars may become keloids; 
 callus may never be absorbed entirely; bones, the seat of osteo- 
 myelitis, may remain permanently thickened; lymph-edema may suc- 
 ceed to cellulitis. Atrophy, on the contrary, may take the i)lace of a 
 return to the normal; in coxalgia the head of the femur may disappear 
 by interstitial absorption. 
 
 Chronic Inflammation. — It is an arbitrary thing to classify inflam- 
 mation as acute, subacute, and chronic. The former has })een described ; 
 the latter is an inflammatory affection of long duration, and charac- 
 terized by slight or moderate reaction. Subacute is a mean between 
 the two. The error should not be made of classing with chronic inflam- 
 mation certain results of previous inflammations, which consist 
 essentially in the formation of scar tissue or dift'use fibrosis. It is 
 better to speak of such changes as old inflammations; and to limit 
 the term chronic inflammation to a process of reaction which is still 
 going on, even if very sluggishly. For strictly speaking a chronic 
 inflammation is merely one in which the irritant is weak, but con- 
 tinues long in action; in which only a slight reaction is produced, and 
 in which some factor prevents healing. This reaction is not wont to 
 go beyond the stage of formation of granulation tissue. The attacking 
 force and the repelling garrison are so equally matched that neither 
 can well overcome the other; cell accumulation is marked, but phago- 
 cytic power is slight; exudation is slight; tendency to suppuration is 
 si ght. Such inflammations are seen in the case of the infect ions 
 granulomas. When healing occurs, the scar-tissue formed is propor- 
 tionate to the previous hyperplastic condition. 
 
 The symptoms are similar, but less in degree, than those seen in 
 acute inflammation. As might be expected from what is known of 
 the pathology of chronic inflammations, swelling is the most char- 
 acteristic s^aiiptom. Pain usually is moderate, but may be intense, 
 especially in bones and joints. Redness is slight. Heat often cannot 
 be detected. 
 
 Treatment of Inflammation. — Prophylaxis. — The consideration of 
 the treatment of inflammation involves first of all a study of the 
 means of prevention. Inflammation, even when it has once com- 
 menced, frequently may be aborted by the prompt removal of the 
 cause. If the insult to the tissues be due to a foreign body, the removal 
 of the foreign body will prevent the reaction which its prolonged pres- 
 ence undoubtedly would provoke. The removal of a cinder from the 
 eye may pre^'ent the development of conjunctivitis; that of a splinter 
 from the finger may prevent the formation of a felon. In some 
 diseases and in certain parts of the body, prompt excision or amputa- 
 tion of the diseased member will prevent the development of an inflam- 
 mation which might proNe fatal. Prompt amputation of a hopelessly 
 
36 INFLAMMATION 
 
 mangled limb will prevent gangrene and subsequent infection; imme- 
 diate removal of an inflamed appendix will abort the disease by 
 removing its cause, before the inflammatory reaction has spread to 
 the peritoneum. 
 
 As bacteria are the most frequent causes of inflammation, this may 
 be most surely guarded against by preventing the entrance of bacteria 
 into wounds, or by removing them or killing them after their entrance 
 has been effected. The condition of the tissues when infected by 
 bacteria is known as Sepsis; Asepsis is the condition when no bac- 
 teria are present; Antisepsis is a method by which bacteria are com- 
 bated by certain chemicals termed Antiseptics. The constant use of 
 antiseptics on living tissues is open to the objection that the tissues 
 are injured as well as the bacteria; though it is true that usually the 
 injury to the tissues is insignificant. ^Yhen once bacteria have gained 
 entrance to the tissues there are only two ways by which their destruc- 
 tion can be effected; the first is by the natural reaction of the tissues 
 which we call inflammation, and which may be assisted artificially 
 by the use of sera or vaccines (p. 44), the other method is by the 
 direct introduction of antiseptics into the open wound. 
 
 It has been learned by long and costly experience that pathogenic 
 bacteria are everj'where present in civilization, and that mere ordi- 
 nary cleanliness will not suffice to exclude them. They are not 
 present in the air, however, unless this be dust laden, in number 
 sufficient to be harmful; they are carried from place to place only 
 by actual contact of instruments, dressings, etc., on which they may 
 have lodged. They may be killed by boiling, or by dry heat at a 
 sufficiently high temperature; and the instruments, dressings, etc., 
 thus sterilized will, therefore, be aseptic. But unless the surgeon's or 
 the nurse's hands be also aseptic, the mere momentary contact of 
 such hands, or of any other unsterilized thing, with the aseptic 
 instruments or dressings, will at once be liable to contaminate them, 
 and they will again become septic — to what degree no one can tell. 
 Neither the hands of the surgeon nor the skin of the patient can be 
 sterilized by boiling or by dry heat; but by thorough washing in 
 soap and water, and by the use of certain chemicals, practically all 
 the bacteria present on the surfaces so treated may be removed; 
 and those still remaining may be remlererl so inert that they will be 
 incapable of exciting inflammation. As an additional precaution, 
 boiled gloves of thin rubber may be worn. 
 
 The introduction of the practice of asepsis and antisepsis in surgery 
 dates from 1S07, when Lister published his first observations on the 
 antiseptic method of wound treatment; his practice was founded on 
 and confirmed by the researches of Pasteur, concerning fermentation 
 and putrefaction; and although the science of bacteriology may be 
 said to date from the discovery of the Bacillus tuberculosis by Koch, 
 in 1SS2, the great advances made in modern surgery undoubtedly owe 
 their existence to Lister's initiative. When no antiseptics were used, 
 the healing of wounds was tedious in the extreme, and the inflammatory 
 
LOCAL REMEDIAL THE AT ME XT .',7 
 
 reactinii practically always exteiuled to the stage of pus forniation. 
 SiiKf the introduction of the i)ractice of asepsis and .antisepsis, sur- 
 geons have heconie accustomed to jiaving their wounds heal with 
 little or with no apparent inflammatory reaction. Oilier reported a 
 mortality of 80 per cent, from excisions of the knee hefore adopting 
 the antiseptic method; after adopting this method, his mortality 
 fell to 14 per cent.' 
 
 Asepsis is generally acknowledged to he letter than antisepsis, 
 whenever it is practicable. In operative wounds asepsis is usually 
 possible; but when the wound is infected before it comes under the 
 surgeon's care, it is usually safer to adopt antiseptic principles. 
 Wounds ant] wnuiid treatment are discussed in Chapter VI. 
 
 Cure of Inflammation. — The remedial treatment of inflammation 
 may be divided into the Local and the Constitutional. Under the 
 former head are included such methods as Rest of the inflamed 
 part; its Position; the use of Heat and Cold; Xarcotics and Counter- 
 irritants; Bleeding, Leeching, etc.; Incisions and Operations; Compres- 
 sion; Active and Passive Congestion; Massage, etc. Under the latter 
 will be considered Constitutional Rest; Diet; Drugs; and the curative 
 use of varrines, sera, and opsonins. 
 
 Local Remedial Treatment. — Rest of the inflamed part is desirable 
 to decrease the hyperemia and congestion, when these are excessive; 
 to lessen the cellular infiltrate and the exudation; and to enable all 
 the forces of nature to be exerted in overcoming the causes of disease, 
 instead of expending their strength in unnecessary physiological pro- 
 cesses which functional use of the part would entail. Rest in bed is 
 indispensable in a great many inflammations of the head, trunk, and 
 lower extremities. Rest may be procured by the use of splints, when 
 these are sufficient, as in many fractures, wounds of the extremities, 
 felons, etc.; by gypsum cases when rest for a longer period is desirable, 
 as in inflammations of certain joints; by bandages, or strapping icith 
 adhesive plaster, as in fractures of the ribs, slight sprains, etc. P inally 
 rest may be procured by position. 
 
 Position is of importance, because neglect to elevate an inflamed 
 part, and thus to prevent or lessen congestion, may markedly increase 
 the pain; may favor the occurrence of suppuration or sloughing; 
 or invite gangrene by interference with the natural circulation of the 
 part. Carrying the hand in a sling; keeping the foot elevated on a 
 stool; or even going to bed for a time, will each of them prove of 
 benefit in special cases. 
 
 Cold is an invaluable agent in the treatment of inflammation in its 
 early stages. It is anesthetic, benumbing the part and lessening pain; 
 it constricts the bloodvessels, decreasing the hyperemia, and some- 
 
 1 It is true that the late Prof. Ashhurst (1895), in a series of 84 excisions of the 
 knee-joint, had a mortaUty of only 8. -3 per cent., the series extending through both 
 pre-antiseptic and antiseptic periods; yet it is to be noted that he uniformly used 
 scrupulous cleanhness, and virtual anti.septics (turpentine, alcohol, potassium 
 permanganate) even before adopting Lister's principles of wound treatment. 
 
38 INFLAMMATION 
 
 times prcventino: excessive effusion; and it is not impossible that ; 
 lessens the physiological activities of a part, thus promoting rest. 
 It probably lessens peristalsis in cases of peritonitis. Its chief use, 
 however, is in inflammations of traumatic origin — wounds of the soft 
 parts, sprains, etc. 
 
 It may be applied either dry or moisi. The use of moist cold is apt 
 to macerate the skin; but for short periods of time moist cold is very 
 useful, as well in open wounds as in the case of subcutaneous injuries. 
 In crushes of the extremities it is often possible to prevent wide- 
 spread sloughing by the use of irrigation. If more elaborate appli- 
 ances are not at hand, a pitcher may be hung over the affected part 
 and a strip of gauze arranged to act by syphonage (Fig. 120). Dry 
 cold is most conveniently applied by means of the ice bag; in using 
 this, care should be taken to see that a fold of dry lint or a dry towel 
 is kept between the skin and the ice bag, as the condensation on the 
 surface of the latter will soon render the skin wet, and may cause 
 superficial sloughing. Or Petitgand's method of mediate irrigation 
 may be employed: a coil of thin-walled rubber tubing, of convenient 
 length, is wrapped around the limb, or applied to the head, the breast, 
 etc., and is held in place l)y a few turns of a roller bandage; a stream 
 of cold water is then allowed to trickle constantly through the tube, 
 being collected beside the bed in a suitable receptacle. The tempera- 
 ture to which the surface of the inflamed part has been reduced may be 
 ascertained by testing the fluid as it runs off". Leiter's coils, which 
 may be purchased ready made, are of flexible metal. 
 
 Heat, like cold, constringes the vessels of an inflamed part, and 
 though not actually anesthesic, may prove more grateful to the patient. 
 In the form of a hot water bag, dry heat is a household remedy. 
 Baking is a valuable remedy in chronic inflammation. ]Moist heat is 
 more often employed in acute inflammation than is dry. It is useful in 
 sprains, etc., as an earlj' application (hot water bath), having a tend- 
 ency to limit or to prevent the development of subcutaneous edema. 
 It is much more stimulating than cold, and when the circulation is 
 sluggish, and sloughing is threatened, the surgeon may sometimes 
 a^'ert the danger by the use of very hot compresses frequently renewed. 
 The use of moist heat in the form of a poultice is very agreeable to 
 the patient, and is one of the most efficient ways of promoting sup- 
 puration when this is inevitable, as well as in hastening the separation 
 of sloughs when these have once formed. The poultice may be made 
 aseptic by sterilizing its ingredients, or antiseptic by incorporating 
 antiseptic substances in it when it is being made. A poultice to be 
 useful should be well made; and unless the surgeon knows himself 
 how to make it well, he cannot expect nurses or other attendants 
 to be particularly careful in its preparation. Linseed and slippery 
 elm bark are the usual substances employed. For the separation of 
 sloughs the yeast, or fermenting poultice is useful. The addition of 
 powdered charcoal will make the poultice efficacious in absorbing 
 malodorous gases. The method of preparing poultices is described 
 
LOCAL UEMEDIAL TREATMENT 39 
 
 in Chapter V. All poultices should he covered with wtixed paper or 
 other iuipernieahlc material, so as to retain their heat and moisture. In 
 the treatment of badly infected wounds, cellulitis, etc., I have derived 
 «>;reat benefit from \\<\\\^ an antiseptic j)<)ultice composed of gauze 
 soaked in ecjual parts of ('»() i)er cent, alcohol and corrosive sublimate 
 solution (i to 2()(K)), applied dripi)in<f wet, and thoroughly covered by 
 waxed paper and absorbent cotton; the whole dressing is then held in 
 place by a roller l)andage. It is sometimes said that there is no need 
 to use antiseptics in wounds which already are infected, and that 
 further infection will do good by establishing a free discharge of pus. 
 This is an error; if there is no discharge of laudable pus in infected 
 wounds, it only shows that the inflammation is extending, and that 
 the body tissues have not been able to produce a sufficient immber 
 of ])hagocytes to combat and to vanquish the invaders. Adding to 
 the infection, or producing a mixed infection, will not mend matters; 
 it should rather be the surgeon's care to support his patient's strength, 
 and to aid his tissues in the unequal struggle by destroying as many 
 as possible of the microorganisms already present. 
 
 The alternation of heat and cold, in the form of douches, is useful in 
 the later stages of the inflammatory process, aiding in the absorption 
 of exudates and the restoration of the part to the normal condition. 
 
 Narcotics sometimes are applied locally with benefit. The tincture 
 of arnica, lead water with laudanum or alcohol, and lately* magnesium 
 sulphate, have been popular at various times. The last named sub- 
 stance has the effect of a local anesthetic, and very remarkable effects 
 are claimed from its use in erysipelas (Tucker, 1908), arthritis, orchitis, 
 and other affections. Belladonna plaster is a favorite domestic remedy. 
 Ichthyol, in the form of an ointment of 10 to 25 per cent, strength, 
 is useful in soothing the pain of adenitis, in furuncles, etc., and by its 
 sorbefacient effect seems to exert a directly beneficial influence on the 
 course of inflammation. Ointments of belladonna and mercury are 
 used in the same way. The internal use of mercury and the iodides 
 may be combined advantageously with these local applications. 
 
 Counter-irritants, when applied around but not directly over the 
 inflamed part, are often productive of considerable benefit, especially 
 in subacute and chronic inflammations, though their exact mode of 
 action is still a matter of dispute. Under this heading come blisters, 
 iodin, turpentine stupes, capsicum and mustard plasters; also silver 
 nitrate, which is astringent, and copper sulphate. The actual cautery 
 is occasionally of value as a counter-irritant. 
 
 Local bleediyig, by the use of incisions, or by means of leeches, may 
 be of value in combating excessive inflammatory reaction. It will 
 relieve the congestion, may perhaps prevent the formation of a harm- 
 ful exudate, and almost without exception diminishes the pain. 
 Leeches are seldom employed at the present day except in affections 
 of the eye and ear. Venesection, or general bleeding, is now rarely 
 employed. In cerebral compression its use is illogical, since the 
 increased arterial tension is the effect, not the cause, of the lesion 
 
40 INFLAMMATION 
 
 within the cranium. But in the robust, plethoric, or cyanosed, with 
 symptoms of present or threatening toxemia, in the presence of 
 inflammation of the sthenic type, venesection is sometimes of value. 
 
 'J'hc use of incisions has already been referred to under the head 
 of bleeding; by relieving tension they serve to lessen the pain, and 
 may prevent sloughing by promoting discharge from the over-filled 
 vessels of the inflamed area, thus aiding in the restoration of the 
 circulation. The pain of orchitis is readily relieved by puncture of 
 the tunica albuginea; after plastic operations (for hypospadias, etc.) 
 multiple small incisions may prevent sloughing by reducing the 
 edema; in extensive cellulitis the use of free incisions may prevent 
 the development of widespread sloughing or gangrene (as in extrava- 
 sation of urine). Finally the evacuation of pus is one of the main 
 indications for incision. 
 
 Operations are frequently required in the treatment of inflamma- 
 tion. Drainage must be established in suppurative affections in all 
 parts of the body (brain abscess; empyema; peritonitis); an invo- 
 lucrum must be cut away; sequestra must be remo^'e(l; amputation 
 and excisions must be performed, before the ultimate cure of the 
 disease can be effected. 
 
 Compression, applied before the inflammatory process has reached 
 its height, may prevent excessive reaction; in the later stages it will 
 assist in promoting absorption. Swelling of a sprained ankle may be 
 prevented by strapping ; a carbuncle will rapidly decrease in size when 
 thoroughly suported at its periphery by adhesive plaster straps; 
 strapping a leg ulcer is almost indispensable at times. 
 
 Aciire and passive congestion, as introduced by Bier (1905), act in 
 a truly remarkable manner in some inflammatory aftections. Con- 
 gestion lessens the pain by benumbing the p&rt, probably by direct 
 pressure on the nerve endings through the subcutaneous edema pro- 
 duced, acting thus much like the usual forms of infiltration anesthesia. 
 It produces its curative effect probal)ly by increasing the number of 
 phagocytes in the part; possibly also by increasing the quantity of 
 the exudate and thus enhancing its bactericidal properties. It has 
 seemed to me that the value of compression in carbuncles and chronic 
 ulcers may be due at least in some measure to the chroiiic passive 
 hyperemia produced. Passive congestion is most used in the treatment 
 of chronic arthritis; it is also of value in such localized infections as 
 furuncles, felons, etc.; it is usually useless or actually harmful in 
 spreading inflammations. Passive congestion is to be secured by 
 bandaging the liml) some distance above the lesion with an elastic 
 bandage which is drawn tight enough to obstruct the venous current 
 without intercepting the arterial. The limb below the seat of the con- 
 striction should develop a comforting glow, the superficial venules 
 being distended, and the skin becoming a dusky blue. Under no cir- 
 cumstances should the constriction be tight enough to cause a fall of 
 temperature in the limb. At first the treatment is continued for only 
 one hour dailv, but later mav be used almost continuously. Active 
 
CONSriTJTlOSAL TRKATMEST 41 
 
 hyperemia is securctl hy liot air apijlicatioiis (hakiiiji (ir tlic hot air 
 tloiK-he), or l)y the list- of ciipj)in^f ^Masse>, which are made in torm> 
 suitable to the various parts arteeted. leaking is partieuhiriy appHcahie 
 to chrouie forms of artliritis witliout efi'usion; wliile the eupi)in^ glass 
 apparatus is said to he of value in tlie treatment of chronic sinuses, 
 ete. ; it has also been used in uterine attections. It is probable that the 
 novelt\' of this treatment is causing it to be indiscriminately employed 
 in many atieetions where it can only do harm. 
 
 Massage is of value in the later stages of inflammation, by pro- 
 moting absorption of the exudate, rupturing slight inflammatory adhe- 
 sions; and thus aiding the restoration of normal i:)hysiological action. 
 In enforced confinement to bed, massage may be advisable to sustain 
 the tone of the muscles of those parts not directly concerned in the 
 disease. 
 
 Constitutional Treatment. — ConstituiionaJ rest, as well as local rest 
 of the inflamed })art, is often requisite. Rest in bed, in a quiet, cool, 
 darkened room, may enable the patient to be restored to his activi- 
 ties in a few days, whereas a much longer period frequently would be 
 required were he to persist in going about the house. Especially 
 should such rest be insisted upon in the case of acute inflammations 
 of the chief organs of the body — pyelitis, cystitis, prostatitis, affec- 
 tions of the gall-bladder and other abdominal organs. 
 
 Hy(/iene is of the utmost importance. The room of the patient, 
 or the hospital ward, should be well ventilated, and easily warmed 
 in winter, and cool in summer. Bathing must not be neglected, for 
 the skin is an important excretory organ. The excretions must be 
 watched daily, and in most cases a careful examination of the urine 
 should be made, both as to quality and quantity. Cathartics should 
 be given as needed; a brisk purge early in the attack is usually bene- 
 ficial. A temperature chart should be kept, and the temperature, 
 pulse, and respiration be recorded twice daily. As the patient will 
 often be unable to entertain himself while laid up, the surgeon should 
 see that such light entertainment as is deemed suitable is provided. 
 The best surgeons are physicians also, and must not let their pro- 
 fessional duty cease with the dressing of the wound or the applica- 
 tion of a splint. On the other hand, I have sometimes seen patients 
 who were exhausted by over-entertainment, all the members of the 
 family congregating in the sick man's room to spend the evening, 
 vitiating the atmosphere, and wearying the patient's mind by constant 
 chattering among themselves. It is usually well to limit the visitors 
 to two at a time; and to caution them to cease their visit and their 
 conversation when the sick man no longer appears interested. 
 
 The diet in cases of inflammation should be simple; so long as fever 
 continues, liquid diet is preferable. ^Milk, which is the most univer- 
 sally applicable article of food, usually can be taken by any patient, 
 in spite of his prejudices, if he makes the attempt, ajid if the milk is 
 fresh and cold. A few patients prefer it warmed. Its taste may be 
 disguised by the use of vanilla, chocolate, coffee, etc. All kinds of 
 
42 INFLAMMATION 
 
 broths are suitable; fresh beef jiiiee often is rehshed, or the various 
 prepared forms of meat juice may l)e employed. Liquid peptonoids 
 is an excellent article of diet. When the fever has gone, more liberal 
 diet may be allowed : eggs, oysters, sweetbreads, chicken, chops, green 
 vegetables, ice-cream, etc. As a rule, the patient's own desires and 
 tastes furnish a fairly reliable guide to his diet; and if no injurious 
 effects are manifest, he may be permitted to eat pretty much what he 
 pleases. 
 
 Drugs are of undoubted value in the treatment of inflammation. 
 Those most employed may be classed as (1) Sedatives; (2) Cathartics; 
 (3) Diuretics and Diaphoretics; (4) Stimulants; (5) Alteratives; (6) 
 Tonics. 
 
 Sedatives.- — Opium is one of the most valuable single remedies in 
 the pharmacopoeia; but its tendency to produce constipation must 
 be guarded against; and it is too valuable a remedy to be used indis- 
 criminately. I never prescribe it unless there appears to be a definite 
 therapeutic indication for its use; I consider its routine use in opera- 
 tions or other surgical affections as extremely injudicious. If the 
 patient is in pain, it is the surgeon's duty to relieve the pain so far as 
 is compatible with the cure of the disease; but usually pain may be 
 relieved without resort to opium, by change of position, by prompt 
 incision of an abscess, or by rest enforced by splint or bandages. If 
 the pain really demands morphin for its relief, I think it is usually 
 better to administer one-sixth of a grain hypodermically, and to 
 repeat this in an hour if the patient is not relieved. In extensive 
 burns, I order a quarter of a grain for an adult immediately, and have 
 this dose repeated at short intervals until relief is obtained. There is 
 no torture so great as that of a burn so extensive as to ensure death 
 within a few hours; and it is inhuman to withhold the means of euthan- 
 asia from such patients. Closely allied to its power of producing sleep, 
 is the action of opium for injuries of the head, in traumatic delirium, 
 delirium tremens, etc. Besides relieving pain and securing sleep, 
 opium serves to relax spasm; it thus proves of benefit in fractures; 
 in retention of urine from congestion of the posterior urethra, in fissure 
 of the anus, in pylorospasm, and similar aft'ections. 
 
 If opium is contraindicated, other sedatives may take its place; 
 among the most valuable of these are chloral, the bromides, hyoscin, 
 cannabis indica, and paraldehyde. Trional is a useful hypnotic, but 
 has no influence on pain. Aconite may be given in small doses during 
 the height of the inflammatory fever, when of the sthenic type. 
 Veratrum viride and antimony are now seldom used. The latter was 
 formerly employed in the endeavor to abort inflammation by means 
 of its so-called "anticipatory antiplastic eftect." Calomel, for the 
 same purpose, was strongly commended by the late Prof. Ashhurst, 
 in the treatment of head injuries, and I constantly employ it with 
 utmost satisfaction. 
 
 Catharatics usually may be administered with benefit in the early 
 stages of inflammation. In this way toxins are withdrawn from the 
 circulating blood, and prevented from reaching the kidneys in excess, 
 
CONSTirVTIONAL TREATMENT 43 
 
 u here they ;ire prone to ciiuse (•h)U(ly swelhii''' or (les(|ii;iiiiat i\ c neph- 
 ritis. In ])eritonitis 1 heHe\e the use ol' eathiirties to he positively 
 harinfiil. In inenin<;itis it is desirahle to keep the bowels freely oj)en. 
 A single dose of castor oil, or blue i)ill, or divided doses of calomel 
 (gr. g hourly till gr. j has been taken) will be of more benefit in most 
 cases than the popular use of salts. After having the bowels thoroughly 
 o])ened once, it is usually inadvisahle to continue purging the patient. 
 If constii)ation i)ersists, enemas may be used. AsafVx'tida supposi- 
 tories, or milk of asafoetida by enema, are supposed to overcome 
 flatulence. 1 have considerable doubt whether they have any very 
 definite action. 
 
 Diurciics and diaphoretics were much employed formerly, and 
 they undoubtedly are of benefit in some cases. Plenty of water by 
 mouth is the best diuretic; when this is contraindicated, or if it can- 
 not be taken, resort may be had to rectal, subcutaneous, or intraven- 
 ous injections of saline solution. The kidneys are the chief organs of 
 elimination for the toxins produced at the seat of inflammation, and 
 by the iml)ibition of plenty of fluid the function of the kidneys is 
 promoted, and the toxins are excreted in a more or less diluted form. 
 
 Dover's powder combines the merits of an hypnotic with those 
 of a diaphoretic. The vegetable salts of potassium and ammonium 
 (citrate and acetate) are especially valuable as diuretics because they 
 are not themselves irritating; moreover, they lessen the viscosity of 
 the blood. Digitalis and strophanthus are more stimulating; these, 
 or the citrate of caff'ein, may be used when the heart shows signs of 
 failure. 
 
 Stivwiants seldom can be dispensed with in severe cases after the 
 height of the fever has passed. Alcohol, when taken in small quanti- 
 ties, aids the al)sorption of food; it seems to act almost as a food itself 
 when little else can be retained. It should be given in doses large 
 enough to produce the desired effect; the amount naturally will vary 
 with the age and habits of the patient, with his general condition, 
 and with the condition of his heart and kidneys. The initial dose 
 should be small (one-half ounce three or four times daily), and it 
 should be increased rapidly so long as it appears to do good. In men- 
 ingitis it is contraindicated, as tending to increase delirium; but in 
 delirious states due purely to adynamia, as in extensive burns, or 
 other exhausting diseases, the use of tonic doses of alcohol frequently 
 will cause the mental state to clear up promptly. Its use in delirium 
 tremens is to be condemned. If the delirium, from any cause, is 
 increased by the alcohol, it is doing the patient no good, and should 
 be reduced in quantity or discontinued entirely. Whisky and brandy 
 are the })est forms in which to administer alcohol during the inflam- 
 mation; during convalescence, ale, beer, porter, or the lighter wines 
 may be used. Champagne is the only form in which it is usually 
 advisable to administer alcohol during the continuance of high fever. 
 
 Coffee is a valuable stimulant. It may be administered by mouth 
 or bv enema. The same is true of salt solution, as alreadv noted when 
 
44 INFLAMMATION 
 
 speakinjj; of diuretics. Atropiu, (li<i;italis, and camphor are ^ooi\ 
 cardiac and vascular stimulants. I do not think much of strychnin 
 except as a tonic. 
 
 Alteratives are used frequently in inflammation. The em{)loyment 
 of mercury to cause the absorption of inflammatory exudates (iritis, 
 meningitis, etc.) is world-wide. Calomel is usually the best form for 
 administration. The iodides of potassium, sodium, etc., are widely 
 used to aid in the elimination of inflammatory products, especially 
 in affections of the bones and joints. 
 
 Tonics.— Dwvmg convalescence it is almost always proper for the 
 patient to take a tonic. Iron and quinin are the most valuable. 
 Some patients will prefer Blaud's pills to the tincture of the chloride 
 of iron, but the latter frequently is more eft'ective. The tincture of 
 nux vomica, or strychnin sulphate, with one of the bitters, aids 
 materially in the restoration of appetite. In the case of children, 
 cod liver oil, the phosphates, or arsenic may be given. 
 
 Stimulation of Phagocytosis. — This method has been attempted in 
 both the prevention and treatment of inflammation. Mikulicz used 
 local hypodermic injections of dilute nucleinic acid, in the effort to 
 increase by positive chemotaxis the number of phagocytes and their 
 bactericidal power for the prevention of peritonitis. Local inunctions 
 of mercury are said to act in a similar way. The use of Bier's passive 
 hyperemia has already been referred to. 
 
 Vaccines and Serum Therapy in General; the Opsonic Theory. — The 
 phenomena of the inflammatory process are merely exaggerations 
 of phenomena which are constantly occurring in the body in a state 
 of health. As already mentioned, it is extremely probable that 
 bacteria of some kind are constantly present in the body, and that 
 phenomena of disease are prevented only by the natural resistance 
 of the body tissues. Opsonins, as pointed out at p. 23, are normally 
 present in the fluids of the circulating blood. When local inflamma- 
 tion or general disease arises, these resistive powers of the organism 
 are increased; various other antibodies are produced, and on recovery 
 from a certain disease a condition of immunity to that special infec- 
 tion may be established, and may continue for a longer or a shorter 
 time. This immunity may be conceived of as being due to the cells 
 of the body having acquired by training the habit of resisting a certain 
 specific infection; so that should this same infection again occur, the 
 body cells would be fully prepared, as the result of their previous 
 experience, to act rapidly and eftectively in repelling the foe. Their 
 habit of forming antibodies will result in attempts at re-infection 
 proving ineft'ectual. 
 
 The earliest instance in which practical application was made of 
 the above theory, though of course the principle itself was not then 
 understood, was the use of vaccination by Jenner (1798); in the origi- 
 nal method the virus of the cowpox was inoculated into man, thus 
 producing in him the disease known as vaccinia, which was considered 
 to be a mild form of smallpox, the virulence of the smallpox virus 
 
VACCINES AM) SKRVM TIIEHAI'Y IN GENERAL 45 
 
 having beeiv attenuated by passing through tlie cow. \\\ thus training 
 the body cells to reaction against the ^■irus of cowijox, an iiinnunity 
 to smallpox is estal)lished. 
 
 The term vaccines is apj)lied to those substances, used for pro- 
 phylactic or curative injection, which contain the attenuated virus 
 itself, not merely some of the anti-bodies profluced in the course of 
 the disease. Most vaccines contain no bacteria which have not been 
 killed. Those substances whic-h contain anti-bodies an'l i)erhaps 
 dead bacteria, but certainly no living virus, are classed as sera; they are 
 subdixided into aniitoxic and antibacterial sera. By the use of the 
 opsonic index, the use of vaecines and sera may be judiciously con- 
 trolled. By collecting in a capillary pipette equal amounts of (1) the 
 ])atient's blood serum, (2) blood corpuscles washed in a solution of 
 one-half per cent, sodium citrate in normal salt solution, and (3) 
 an emulsion of the specific bacteria of the disease from which the 
 patient suffers; and by then examining properly pre])ared slides 
 spread with the above fluid, the average number of bacteria ingested 
 by each polynuclear leukocyte is determined. By comparing this 
 average number with the average number of similar bacteria ingested 
 by the leukocytes in a fluid similarly prepared from the serum of a 
 normal indixidual, we obtain a ratio which may be expressed as an 
 index by reducing the formula to unity. Thus if the average number 
 of bacteria ingested in the first examination (the patient) was 2, and 
 that in the second examination (normal individual) was 4, we obtain 
 a ratio of 2 to 4, or of 0.5 to 1.0. We then speak of 1.0 as the normal 
 opsonic index, and record the opsonic index of the patient as 0.5 
 (Primrose, 1907). By means of this opsonic index it is possible, in 
 a way which so far is still rather empirical, to administer vaccines 
 and sera so as to increase tlie patient's opsonic index, and thus 
 promote the cure of the disease. This method has been employed 
 chiefly in the treatment of tuberculosis. 
 
 Prophylaxis and treatment by vaccines and sera are most suc- 
 cessful in the case of diseases caused by specific microorganisms. 
 Ordinary inflammations, in which the cause is not a specific micro- 
 organism, have not so far been treated with very encouraging results. 
 Among diseases treated by vaccines may be mentioned, besides the 
 prevention of smallpox already referred to, the prophylaxis and cure 
 of anthrax (Pasteur), rabies (Pasteur), typhoid fever (Frankel, 
 Richardson), and tuberculosis (Koch, AVright). Among those treated 
 by sera are included: (1) By antitoxic sera, diphtheria (Behring), 
 tetanus (Behring) ; (2) By antibacterial sera, typhoid, cholera, plague, 
 dysentery, etc. Finally by the administration of both vaccines (active 
 immunization) and sera (passive immunization), encouraging results 
 have been obtained in anthrax by vSclavo (1903). 
 
 Antistreptococcic serum has been extensively used on general 
 principles in ordinary types of spreading inflammation, in erysipelas, 
 and in septicemia. (See Chapter II.) It is an antibacterial serum. 
 The results are sometives mar\ellous, while more often its use appears 
 
4ri IN FLA MM A TION 
 
 to be devoid of effect of any kind. Anticolon bacillus serum has also 
 been used by some observers, but without very constant results. 
 As a general statement, it may be said that in acute diseases, where 
 it is necessary to supply the patient with anti-bodies already formed, 
 sera are used; while in chronic infections, it is hoped by the adminis- 
 tration of killed bacteria to rouse the patient's tissues to a more 
 effectual production of anti-bodies. 
 
CHAPTER II. 
 
 DISEASES RESULTING FROM INFLAMMATION. 
 
 The .siirfi;ical diseases resulting from inflamiiiatioii may be elassified 
 as (1) Local Affections, incliuling Abscess, Ulcer, Gangrene, Cellulitis, 
 Erysipelas, etc.; and (2) General Affections, iucludino; under the gen- 
 eral name of Sepsis, the varieties of systemic infection known as 
 Sapremia, Toxemia, Bacteriemia (Septicemia), and Pyemia. 
 
 LOCAL AFFECTIONS. 
 
 Abscess. — The pathogenesis of an abscess has been described 
 already (p. 25), and it may be defined as a collection of pus circum- 
 scribed by granulation tissue. If the pus is not circumscribed by 
 granulation tissue, it is not spoken of as an abscess. Thus pus in the 
 pleural cavity is an empyema, if widely diffused; it does not become 
 an abscess until it is walled off from the general cavity by the effusion 
 of lymph and the production of adhesions. Pus widely infiltrating 
 the cellular or muscular tissues does not form an abscess, but a 
 phlegmon. Pus free in the peritoneal cavity is described not as an 
 abscess of the peritoneum, but as diffuse suppurative peritonitis. 
 
 Two main varieties of abscess are recognized; these are distinguished 
 clinically by their symptoms, but the pathogenesis of both is the 
 same; they are the acute or phlegmonous abscess, and the chronic, 
 cold, or scrofulous abscess. The former alone is to be considered 
 here ; cold abscess is described in connection with surgical tuberculosis, 
 in Chapter III. 
 
 Clinical Pathology. — An abscess may arise in any place where 
 inflammation exists. It may be caused by direct injury of the part, 
 as by a fall, a kick, an infected wound, etc.; or it may arise second- 
 arily, as the result of extension of inflammation from the primary 
 focus. This extension may occur along the subcutaneous (sub- 
 peritoneal, etc.) areolar tissue (causing cellulitis), along the lymphatic 
 channels (causing lymphangeitis), or along the blood stream (causing 
 phlebitis, and very rarely arteritis). When an abscess is suspected 
 in a region which has not been directly injured, careful search should 
 therefore be made for the original focus of infection; and it should 
 not be forgotten that the intervening tissues may show no evidence 
 of disease. Thus a sore on the foot may cause inflammation and 
 eventual suppuration in the femoral or inguinal lymph nodes, without 
 any evidences of lymphangeitis of the leg or thigh. Abscess of the 
 liver may follow appendicitis, the virus of the disease ha\'ing traversed 
 
48 
 
 DISEASES RESULTING FROM INFLAMMATION 
 
 the radicles of the portal vein without leaving evidences of its passage. 
 Infection from a wound of the mouth may spread to the areolar 
 tissue of the neck, and there cause cellulitis and suppuration without 
 giving signs of inflamraation in the tissues of the floor of the mouth 
 through which it passed. But in each and every case, before suppura- 
 tion can occur, the earlier stages of inflammation must have existed 
 in the part in which the abscess is ultimately formed. 
 
 As the pus within the abscess accumulates, by progressive lique- 
 faction necrosis of the surrounding layer of lymph, the size of the 
 abscess increases; it spreads most rapidly in the direction of least 
 resistance (usually toward the skin surface), and pointinrj of the 
 abscess is said to occur when the pus is contained by the epidermis 
 alone. Occasionally an abscess will point and rupture into a 
 neighboring cavity, as a joint, or one of the great serous cavities 
 (pleura, pericardium, etc.) ; but in the case of suppuration in internal 
 organs, sufficient plastic lymph at times is produced to confine the 
 abscess on its inner surface, and to pre\'eut rupture except externally. 
 When an abscess is evacuated, the tract through which it discharges 
 is called a sinus (p. 52). A fistula is a sinus which has two or more 
 openings ; these may be on the skin, or one may be on the skin, another 
 in an internal cavity (intestine, joint, urethra, etc.), or both may be 
 internal openings (as in gastro-colic, recto-vesical, and other similar 
 fistuhe) . 
 
 Fig. 6. — Abscess of the groin, following direct injury, one month previously. 
 Girl, aged eleven years. Episcopal Hospital. 
 
 Symptoms. — At the onset of suppuration, the part alreadN' inflamed 
 becomes more painful, the pain assuming a throbbing or pulsatile 
 character; the tenderness is accentuated; the intense redness of the 
 inflammation fades into a dusky or a bluish hue; the swelling 
 becomes better localized; and frequently the abscess is seen to 
 stand out above the surface of the surrounding skin (Fig. 6). As 
 the amount of fluid within the abscess cavity increases, fluctuation, 
 
ABSCESS 
 
 49 
 
 at first indistinct, becomes unmistakable; the skin over the abscess 
 may (les(|uamate; it becomes thinner and thinner, and finally is 
 entirely deprived of its nutrition at the point of greatest tension. 
 A minute circular slough is then formed at this point, and, when 
 this is cast ofi", the pus from within is discharged, the abscess 
 cavity is more or less obliterated by the pressure of surrounding 
 parts, and the abscess is finally converted into a granulating 
 surface. When suppuration is deeply seated, an abscess may 
 attain a considerable size before producing such characteristic symp- 
 toms. In such cases the overlying skin may become edematous, 
 pitting slightly on pressure, owing to the eft'usion of lymph and 
 serum in the overlying parts; rigidity and immobility of the pro- 
 tecting muscles are important signs; and the experienced touch of 
 the surgeon may enable him to proclaim with certainty the presence 
 of pus, when to one not possessed of the tacius eruditus a positive 
 diagnosis would be impossible. 
 
 Fig. 7. — Instruments used in treatment of abscess: bistoury, eyed probe, 
 dressing forceps, exploring needle. 
 
 Diagnosis. — It is not likely that an acute, superficial abscess, 
 already pointing, will be mistaken for anything else. But there 
 are many other affections with which an abscess at times may be 
 confused. Careful and systematic examination of the patient should 
 therefore never be neglected. The brilliant Irish surgeon, Dease, 
 recklessly plunged his bistoury into a swelling in the femoral region, 
 which he mistook at first glance for an abscess, and his patient died 
 before his eyes from overwhelming and uncontrollable hemorrhage 
 from the femoral artery, an aneurysm of which vessel had been opened. 
 The diagnosis of an acute abscess ma}- be determined by the history, 
 by the local sigm (fluctuation, pointing, etc.), and as a last resort 
 by the exploring needle (Fig. 7). Fluctuation may be present more 
 or less distinctly in many other swellings than those containing pus; 
 besides aneurysms, effusions of blood, of serum, of urine, etc., may 
 produce such fluctuating swellings; and cystic and even fatty and 
 some other solid tumors may give a similar sensation. The surgeon's 
 fingers, moreover, in palpating a suspicious swelling, should be placed 
 longitudinally on the part, since the belly of a large muscle, and 
 4 
 
50 DISEASES RESULTING FROM INFLAMMATION 
 
 even very fatty subcutaneous tissues may present indistinct fluctuation 
 if this point be neglected. The exploring needle, or what is better 
 if at hand, an ordinary hypodermic syringe, may be used to ascertain 
 the presence and nature of the fluid in a doubtful case. 
 
 Prognosis. — This is good in most cases, provided treatment is 
 prompt and efficient. But an abscess may be dangerous from its 
 situation, from its size, or the prognosis may be peculiarly grave 
 from the constitutional condition of the patient, or his age. A 
 retropharyngeal abscess may cause suffocation; one in close proximity 
 to a large bloodvessel may rupture into it, and cause death from 
 hemorrhage or from pyemia; an abscess near a joint may penetrate 
 its capsule and cause lasting disability or even death from pyar- 
 throsis; an abdominal abscess may rupture into the peritoneum and 
 cause fatal peritonitis. The drain on the patient's vitality from a 
 large abscess, or from many smaller abscesses, may lead to death 
 from exhaustion, or from amyloid degeneration of the viscera. In 
 practically every case there will be loss of tissue, and a more or less 
 evident cicatrix for years after the abscess has healed . 
 
 Treatment. — ^Much may be done to prevent the formation of an 
 abscess, as pointed out in discussing the treatment of inflammation. 
 When pus has once formed, much may be done to ameliorate the 
 symptoms, and to cure the patient with as little disfigurement as 
 possible. Though the process of pointing can seldom be hastened, 
 yet by appropriate treatment the sufferings of the patient may be 
 very materially relieved until pointing occurs. Heat or cold, which- 
 ever proves most grateful, may be applied locally, and anodynes may 
 be administered internally, when required. Warm moist heat, in 
 the form of a poultice, usually is most grateful to the inflamed part. 
 But though these adjuvants may be employed with advantage in 
 certain cases, prompt evacuation of the pus by incision is much 
 more efficient in checking pain, by relieving tension and hastening 
 the conversion of the abscess into a superficial ulcer. Moreover, 
 the cicatrix resulting from a well-placed incision is much less dis- 
 figuring than one which occurs when an abscess is allowed to burst 
 of itself. In most abscesses affecting the subcutaneous tissues it is 
 better to postpone incision until fluctuation is evident, and until 
 pointing has nearly occurred; but in other cases incision should be 
 adopted much earlier, general or local anesthesia being employed 
 as may seem indicated. When only the skin intervenes between the 
 abscess and the surface of the body, no anesthetic is required, for 
 freezing the skin or the use of hypodermic injections of cocain is 
 quite as painful as the momentary stab of a bistoury; moreover, 
 the skin overlying such an abscess has nearly all its nerves devitalized 
 by the anemic necrosis induced by pressure of the pus. In the case 
 of deeper abscesses, I much prefer tljc hypodermic use of cocain to 
 freezing by the ethyl chloride spray; and when the cocain is properly 
 used the entire procedure is painless except for the initial prick of 
 the needle. When the abscess is still more inaccessible, general 
 
ABSCESS 
 
 51 
 
 anesthesia is to be preferred, since in some instances it may be 
 necessary to undertake a formal operation, or even to oi)en the abscess 
 across a serous cavity (puhnoiiary, appendicular, cerebral abscess). 
 In opening a superficial abscess without any local anesthesia, the 
 surgeon should accomplish his purpose by a sudden thrust of the 
 bistoury, which is held as a pen, and with its cutting edge toward 
 the surgeon; thus, as the patient draws away in momentary surprise 
 or pain, the .incision will be enlarged as the bistoury is witlidrawn. 
 The dei)th to which it is to be introduced must be determined before- 
 hand, and regard must be had to the anatomy of the part, lest some 
 important nerve or vessel be wounded. In opening an abscess in a 
 dangerous neighborhood it is much safer to adopt Hilton's method: 
 to incise merely through the skin and superficial fascia, and then to 
 introduce a grooved director, and burrow down to the abscess with 
 this, or with a dressing forceps; when the pus is reached, the blades 
 of the forceps are widely separated and the forceps is withdrawn, 
 thus dilating the tract previously made. 
 
 When an abscess has been opened, it should be allowed to dis- 
 charge itself slowly; the surgeon may gently support its sides, to 
 encourage the discharge of pus, but he should by no means attempt 
 to express it by massage, and most em- 
 phatically should he not introduce a 
 curette into the abscess cavity to scrape 
 away its lining membrane. Such a course 
 destroys the granulation tissue surround- 
 ing the abscess cavity, may open neigh- 
 boring venules or lymphatic radicles, 
 and is extremely ai)t to cause a spread 
 of the inflammation. When the tension 
 on the abscess cavity is relieved by the 
 evacuation of the pus, its walls will col- 
 lapse, and in the case of small abscesses 
 union between these apposed walls will 
 take place in a couple of days by the 
 process of secondary adhesion (p. 1G2), 
 anfl a superficial ulcer alone will remain. In such cases no drain need be 
 introduced into the abscess cavity; but in the vast majority of instances 
 it is important to introduce between the lips of the incision some sub- 
 stance which will keep them from uniting until healing of the under- 
 lying abscess cavity is complete. A tube of soft rubber, commonly 
 known as a drainage tube (Fig. 8), is much more satisfactory for 
 this purpose than is any substance, such as gauze, which may become 
 clogged with the discharging pus, and thus hinder, instead of promote 
 the escape of pus from the depths of the cavity as healing progresses. 
 It is only in very small abscesses, where the discharge is slight, that 
 a gauze drain is useful; and if employed in other cases, where it may 
 be of ^■alue by acting as a tampon to check oozing of blood from 
 the walls of the abscess cavity, it is better to use a tube as well; or a 
 
 Fig. S. — Drainage tube of soft 
 rubber, with numerous eyelets. 
 
0'^ 
 
 DISEASES RESULTING FROM INFLAMMATION 
 
 cigarette drain (Fig. 10) may be employed. In small abscesses snffi- 
 cient drainage may often be procured by a few strands of silkworm 
 gut or a })iece of rubber tissue. 
 
 Fig. 9. — Deep abscess of thigh; through-and-through drainage by rubber tube, 
 safety-pins to prevent displacement of tube. Episcopal Hospital. 
 
 The dressings of an abscess (gauze) will absorb the discharges 
 better if they are moist. A solution of sodium chloride, of corrosive 
 sublimate, of alcohol, of potassium permanganate, or other suitable 
 antiseptic may be used for this purpose. The gauze immediately 
 next the dischargins; sinus should be well crumpled up before being 
 applied; laying many layers of flat gauze over the part will dam up 
 the pus in the abscess cavity. 
 
 Fig. 10. — Cigarette drain, made by covering a wick of gauze with rubber tissue. 
 
 Sinus and Fistula. — These are suppurating tracts, usually due to 
 the incomplete healing of abscesses. A sinus, as pointed out at p. 
 48, has only one orifice, since its other extremity ends blindly in 
 the former abscess cavity.^ A fistula, on the other hand, is a suppu- 
 rating tract with at least two, and sometimes several, orifices, which 
 may be either external, internal, or both. Sinuses and fistula may 
 be kept from healing by the action of neighboring muscles (as in 
 fistula in ana) ; by the presence of some foreign body (spicule of bone, 
 ligature) which the tissues of the organism cannot destroy; or by 
 the constant passage of the secretions of the part through the abnor- 
 mal opening (salivary, fecal, or urinary fistula), instead of through 
 the natural channel. 
 
 Treatment. — They should be treated by removal of the foreign 
 body; by removing the obstruction to the discharge of the secre- 
 tions; or by supporting the sides of the sinus with adliesi\'e plaster or 
 bandages to overcome the action of neighboring muscles. If the walls 
 of the suppurating tract are thickened and indurated, they should be 
 
 ' Such a sinus often is called a "blind fistula." 
 
ULCER 53 
 
 stiiniihitt'd \)\ the use (tt" ("lustic iiijcctioiis (sil\ cr nitrate, /.iii<- sulphate, 
 etc.), or stiinulatiiif^ ointments (dilute niereuri<' nitrate, iclitliyol, 
 iodin) oil a rojx' of fiau/e; l)y curettintj the sinus with \'olkmann's 
 sharj) s])oon; or finally by slitting the tract oi)eii on a grooved director, 
 cauteriziiifr it with caustic potash or the actual cautery, thus producinj^ 
 a superficial slouj^h and converting the sinus into an ulcer, and 
 promoting healing from the bottom. In excessively obstinate cases 
 a cure may be obtained by dissecting out the entire suj)purating 
 tract, and uniting the parts from the bottom with buried absorbable 
 sutures. ]\Iany chronic sinuses, especially of tuberculous origin, may 
 be cured bv the injection of a bismuth-vaselin paste, as recommended 
 by Beck (1908) (see Chapter XV). 
 
 Ulcer. — Ulceration is defined as the molecular death of a part. 
 Some writers distinguish between an ulcer and a granulating wound, 
 limiting the former term to the result of the process of destruction 
 known as ulceration, and therefore denying that an ulcer, as such, 
 can ever heal; maintaining that as soon as healing commences the 
 term granulating wound should be adopted. Certain ulcers, however, 
 may be granulating at one portion of their surface, while still actively 
 ulcerating at another point (serpiginous uJceration); so it seems fjetter 
 while acknowledging the distinction between ulceration (molecular 
 death) and granulation (process of repair), to include as is usually 
 done, both granulating and ulcerating surfaces under the general 
 heading of ulcer. Park tersely defines an ulcer as "a surface which 
 is or ought to be granulating." 
 
 The repair of an ulcer occurs by granulation and cicatrization. 
 The formerly ulcerating surface gradually loses its inflamed appear- 
 ance; the discharge of pus lessens; the edges of the ulcer become 
 firmer and more clearly defined; and granulations are seen springing 
 up all over its surface. Soon these granulations become higher than 
 the surrounding skin; often they become exuberant, forming what is 
 known as "proud flesh." Aroung the edges of the ulcer the neighbor- 
 ing epithelium proliferates, gradually covering in the granulations, 
 and being easily distinguished as a faint blue line interposed between 
 the healthy skin and the face of the ulcer. Occasionally little patches 
 of new skin, with this same faint bluish tinge, may be seen in the 
 midst of the granulations, e\idently arising from epithelial cells 
 which have survived the original destructive lesion. As these changes 
 progress on the surface of the ulcer, beneath its surface proceed the 
 changes which have already been described under the heading Repair 
 (p. 29); that is to say, the fibroblasts become converted into white 
 fibrous connective tissue (cicatrization), and as a consequence the 
 face of the ulcer contracts, thus decreasing the superficial area which 
 must be covered over by the surrounding epithelium. This con- 
 traction, which is the prime characteristic of all newh' formed 
 cicatricial tissue, is most noticeable on the surface of the body in 
 the healing of ulcers resulting from burns; and in mucous channels 
 (urethra, esophagus), where strictures are the result. 
 
54 DISEASES RESULTING FROM INFLAMMATION 
 
 Certain varieties of ulcer are descrihcd l)y systematic writers. 
 The most important are: 
 
 Simple or Healthy Ulcer. — This is characterized by its innate 
 tendency to heal. To secure prompt healing every other variety 
 of ulcer must be converted into this form. Ordinary incised wounds 
 healing by "second intention," and superficial burns, afford good 
 examples of a healthy ulcer. This ulcer, if not too large, will heal 
 of its own accord if it be protected from injury. If exposed to the 
 air after the granulations are well formed, a scab will form over it, 
 and healing under the scab will take place as described at p. 162. 
 Ordinarily it is better to cover the ulcer with some mild ointment, 
 spread not too thickly on lint. There is no object in having the 
 ointment spread over the neighboring healthy skin also; indeed to 
 do so freciuently causes maceration and delays healing. 
 
 Inflamed Ulcer. — This is one in wdiich infection is still progressing, 
 the reaction of the tissues being insufficient to quell the invasion 
 (Plate I, Fig. 3). A very severe form of inflamed ulcer is the slough- 
 ing ulcer. The worst form of all is phagedenic ulcer, usually seen only 
 in chancroidal sores; here the destruction of tissue is frightfully 
 rapid, and nothing short of thorough cauterization of the entire 
 ulcerated surfaces will suffice to check the phagedena. In ordinary 
 cases of inflamed ulcer, confinement to bed, with elevation of the 
 part, the local use of antiseptics, and tonics and stimulants inter- 
 nalh', may l)e necessary to arrest ulceration. 
 
 Weak or Edematous Ulcer. — This is characterized by the granu- 
 lations being large and flabby, apparently distended with serum, 
 of very low vitality, and easily detached in masses from the sur- 
 face of the ulcer. Usually it is an evidence that proper care of the 
 wound has been neglected, or that poultices and mild ointments 
 (zinc oxide and boric acid) have been continued too long. As 
 granulations contain no nervous tissue, no hesitation need be felt 
 in snipping off w^ith scissors the exuberant masses of proud flesh; 
 the patient will not feel a particle of pain. Any bleeding is readily 
 checked by pressure or by cauterization with the stick of silver 
 nitrate. Then more stimulating ointments should be applied, par- 
 ticularly valuable being resin cerate, scarlet red, balsam of Peru, 
 nitrate of mercury, ichthyol, etc. 
 
 Neuralgic or Irritable Ulcer. — This is usually of small size, placed 
 at the ankle, below or near to one of the malleoli, and is characterized 
 by the intense pain experienced by the patient. The skin margins 
 are usually thickened, the ulcer has little or no discharge, its surface 
 being glazed and exquisitely sensitive. Frequently it is evident that 
 the ulcer involves the terminal filaments of some sensory nerve, 
 especially the musculocutaneous or the internal saphenous nerves 
 at the ankle (Fig. 11). If rest in bed, with elevation of the part, and 
 cauterization of the base of the ulcer fails to relieve pain, the 
 affected nerve some three to six inches above the ulcer may be 
 stretched or excised (Hilton, 1877). 
 
VLCER 
 
 55 
 
 Indolent or Callous Ulcer. — This is the most frequent form of "le^ 
 ulcer," usually occurriiij^ in achilts, on the lower half of the le^, and 
 on the anterior or fihular aspect. The surface of the ulcer is dry, 
 and sometimes j^la/.ed; the granulations are low and ill-formed; the 
 edges are hypertrophied and dense, and give to the surface of the 
 ulcer a depressed or concave appearance (Fig. 12). As cure depends 
 uj)on contraction of the base of the ulcer, and on concentric cicatri- 
 zation proceeding from its edges, it is evident that destruction of the 
 callous margins is the first step in this direction. These margins 
 surround the ulcer like a cartilaginous ring, and by their lack of 
 elasticity and by their very bulk prevent contraction of the ulcer's 
 base; moreover, the surrounding epithelium appears indolent and 
 unable to proliferate so as to cover in the granulations. The ulcer 
 
 Fig. 11. — Neuralgic or irritable ulcer in a 
 woman, aged forty-five years. Duration four 
 weeks. Episcopal Hospital. 
 
 Fii;. 12. — Indolent or callous ulcer> 
 of the leg. Episcopal Hospital. 
 
 usually is due to some trivial injury, repair of which becomes 
 impossible from the necessity of the patients continuing their occupa- 
 tions as means of livelihood, and because of some constitutional 
 condition (obesity, arteriosclerosis) which interferes with the normal 
 circulation of the blood and lymph in the part. If the patient be 
 put to bed and the callous margins of the ulcer be softened by 
 poultices or simple wet dressings, the ulcer usually will soon be con- 
 verted into one of the healthy type, and cure will soon be brought 
 about. As soon, however, as the patient resumes his occupation, 
 the old ulcer is apt to reappear whenever the skin is bruised. 
 It is important, on this account, to take great pains to avoid 
 injury and to maintain the skin in good condition, when once the 
 ulcer has healed. Scrupulous cleanlinesss should be enjoined; and 
 
ofi 
 
 DISEASES RESULTING FROM IXFLAMMATIOX 
 
 wliere a tendency to edema of the leg exists, much l)enefit may 
 be gained from the use of an elastic bandage, which usually is 
 preferable to an elastic stocking. But it may be impossible for 
 the patient to be laid up in bed for some weeks, which is the 
 shortest time in which a cure may be anticipated; yet even with- 
 out the advantages of rest in the recumbent position, it is by no 
 means impossible to bring about a cure of the ulcer. Poultices and 
 wet dressings may be applied while the patient continues at his 
 work, and when the margins of the ulcer have become reasonably 
 soft, it may be strapped with adhesive plaster, thus supporting the 
 edges, preventing a re-accumulation of blood and lymph in the parts, 
 and mechanically promoting healing of the base. The straps should 
 
 be an inch or an inch and a half 
 wide, long enough to encircle about 
 three-fourths of the limb when 
 obliquely applied ; and are to be put 
 on from below upward in an imbri- 
 cated manner, two at a time, thus 
 drawing the edges of the ulcer to- 
 gether as the two straps are crossed 
 (Fig. 13). The strapping, which 
 should start an inch or so below 
 the tilcer, and continue for an equal 
 distance above its upper margin, 
 should be covered in by a firm 
 muslin bandage, extending from the 
 patient's toes to his knee. This 
 dressing may remain in place for 
 from five days to a week; when it 
 is to be removed, the skin should 
 be washed with turpentine, the 
 edges of the ulcer (just within the 
 blue Ime of new skin) touched 
 with the solid stick of silver nitrate, 
 and the straps again applied and 
 covered in with a firm bandage 
 as before. ^Mien the ulcer assumes the character of a simple or 
 healthy ulcer, strapping may be discontinued, and ointments may 
 by applied; but frequently the ulcer will heal under the use of straps 
 alone. The results of this treatment, when it is carefully carried out, 
 are remarkable: ulcers which have been open for a year or more, 
 and on which all manner of salves have been tried, may be completely 
 healed within comparatively few weeks. It is usually best for the 
 patient to continue to keep the leg bandaged for a long time after 
 apparent cure has been obtained, since relapses are frequent. In 
 the rare cases where rest in bed, poultices, and strapping, fail to cure 
 an indolent ulcer, its conversion into a healthy ulcer sometimes 
 may be accelerated by dividing its callous margin by several radiating 
 
 Fig. 1-3. — Strapping a leg ulcer. 
 Episcopal Hospital. 
 
ULCER 
 
 57 
 
 incisions, or vvvu l)y iiiakiiit;' criss-cross incisions extending' llironfj;h 
 the base of the nicer and its eallons niaruin on l)otli sides. Or the 
 nk'er may he nn(kT-ent I'rom the sides, separatini^; its base c()nii)letely 
 from tlie (k'ep fascia. Skiit gnij'tutg (p. '2'2'A) lias heen employed to 
 hasten the cicatrization of these ulcers, but without much success. 
 Formal plastic operations (p. 225) occasionally have been adopted, 
 but with no very jicrmanent results. A great many of these callous 
 leg ulcers are due to the unsuspected presence of syphilis. Tlie typical 
 syphUiiic leg ulcer (Fig. 14) is situated above the middle of the leg, 
 is characteristically round, is seldom very ])ainfu], and yields with 
 
 Fig. 14. — Syphilitic ulcer of leg, male, 
 aged twenty-four year.s. Following "ru- 
 pia" of six weeks' duration. Completely 
 healed under anti-syphilitic treatment in 
 three weeks. Episcopal Hospital. 
 
 Fiu. 15. — Varicose leg ulcer. 
 Episcopal Hospital. 
 
 remarkable facility to the administration of mercury and the iodides. 
 But in many of the callous ulcers in which no definite history of 
 syphilis can be obtained, much improvement often follows the adminis- 
 tration of potassium iodide alone or with mercury. In almost all 
 cases of leg ulcer of long duration the tibia immediately beneath 
 the seat of disease becomes thickened; but in the case of syphilitic 
 ulcers there is sclerosis of the bones, and as pointed out by Coues 
 the diagnosis of syphilitic leg ulcer usually may be confirmed by a 
 skiagraj)h. In very exceptional cases the callous ulcer is absolutely 
 incurable. But life with an incurable leg ulcer is by no means impos- 
 
58 
 
 DISEASES RESULTIXG FROM IXFLAMMATIOX 
 
 sible; indeed, many persons live for fifteen to twenty years, or longer, 
 with unhealed le*; ulcers, and are able to lead very active lives. It 
 is only in the rarest instances, therefore, that amputation is justi- 
 fiable; for the risk to life usually is much less from an unhealeti leg 
 ulcer than from amputation. 
 
 Varicose Ulcer. — This is one associated with varicose veins (Fig. 15). 
 It is difficult to heal, sometimes is attended by alarming hemorrhages, 
 and frequently incapacitates the patient. The use of elastic bandages, 
 hot baths, gentle massage, etc., by reducing the swelling, and improv- 
 ing the circulation of the limb, sometimes will bring about a cure, 
 or at least will keep the patient in comfort. If palliative measures 
 fail, excision of the affected veins may be done; but the operation 
 is one of more risk than when no ulcer exists, and sliould not be 
 undertaken lightly. It should never be done in the presence of active 
 phleliitis; and if the veins are thrombosed as the result of a former 
 phlef)itis, they should be divided through healthy portions above 
 the limit of tlie clot. 
 
 Warty Ulcer. — Under this name Marjolin (1846) described a form 
 of ulcer which of late years usually has been regarded as due to 
 
 malignant clianges. It is not correct, how- 
 ever, to give the name of Marjolin to every 
 ulcer which undergoes malignant transfor- 
 mation, as his original description applied 
 merely to the clinical appearance of tlie ulcer, 
 as if covered with warts. Fig. 16 represents 
 a typical warty ulcer, whicli healed rapidly 
 under appropriate treatment. When of long 
 standing a malignant ulcer whose surface is 
 warty frequently is found to involve the 
 bone, which is the seat of caries, perhaps due 
 to a primary sarcoma of bone, or possibly 
 involved secondarily by a surface epithelioma. 
 If the warty ulcer is malignant, it is much 
 safer to amputate tlie limb than to attempt 
 excision; but if the malignant ulcer is of the 
 heel (I have seen two cases following burns 
 in this situation), resection may properly be 
 done, with restoration of tlie foot by the 
 method of ^Mikulicz, if the patient refuses 
 amputation. 
 
 Gangrene (sphacelus, mortification, slough- 
 ing) is a term used to describe the process 
 of death of the soft parts, or of an entire 
 extremity with its contained bone, when this death occurs in mass; 
 necrosis, though usually confined in its application to death of bone, is 
 occasionally employed to describe the death of soft parts at a depth 
 from the surface, where no marked inflammatory phenomena are 
 present, the resulting necrotic masses corresponding very closely to 
 
 Fig. 16. — Warty ulcer of 
 Marjolin connected with 
 periosteitis eight months 
 after typhoid fever. From 
 direct injury. Aged fourteen 
 years. Episcopal Hospital. 
 
GANGRENE 
 
 59 
 
 the sequestra met with in necrosis of l)()ne. In ulceration, tlie dead 
 parts are cast otV in tlie form of pus (liquefaction necrosis), and 
 moleriihir drafli of the tissues is sai(l to occur; whereas in f^anj^rene 
 (molar dnttli) the i)arts cast o(f (sloughs) are of such size as to he 
 clearly visible to the naked eye. 
 
 The causes of gangrene are either direct (as in pulpefaction of a 
 limb by crushing force, destruction by caustics, by heat or cold, by 
 bacterial toxins, etc.), or indirect, from interference with the vascular 
 supply. One of the most extensive cases of sloughing I ever saw was 
 
 in a lad of 16 years, whose whole lower 
 
 extremity had passed through cog-wheels; 
 though there was no injur}- to the ^'ascu- 
 lar supply of the limb, the pressure of each 
 cog produced immediate death of the area 
 it crushed, and it was over ten weeks be- 
 fore the sloughs had all separated and the 
 resulting ulcers healed. The appearance 
 of the cicatrices six years after the accident 
 is shown in Fig. 17. Injuries which in a 
 normal state of health would cause only 
 trivial lesions, when complicated by vascu- 
 lar o})struction or constitutional disease 
 mav result in verv extensive sloughing 
 
 Fig. 17. — Cicatrices from 
 sloughing, .six years after in- 
 jury (cog-wheels). Episcopal 
 Hospital. 
 
 Fig. 18. — Gangrene following application for 
 twenty-four hours by patient's mother of carbolic 
 acid dressing. Episcopal Hospital. 
 
 or gangrene. The same degree of inflammatory infiltration, which in 
 the subcutaneous tissues would be harmless, when occurring beneath 
 the palmar fascia or other dense fibrous membrane may produce such 
 a choking off of the ])lood-supply as to cause extensive necrosis of the 
 structures involved. In the old, or in younger persons with marked 
 arteriosclerosis, so-called senile gangrene may follow trifling injuries, 
 or may be caused by gradual occlusion of the arteries without external 
 injury. In diabetics there is a special tendency to necrotic processes, 
 among the mildest of which are furuncles with their central slough or 
 core. In patients suffering from ergotism, gangrene of the fingers or 
 toes, perhaps symmetrical, is a not infrequent phenomenon. It is usually 
 preceded by premonitory symptoms, such as formication, cramps, 
 
60 DISEASES RESULTING FROM INFLAMMATION 
 
 local asphyxia, etc. Certain lesions of the nerwms sysfcin, jirobably 
 through vaso-motor changes, may induce hed-sores, siougliing, etc., 
 in an alarmingly short space of time. The so-called perforating ulcer 
 of the foot (p. 261), probably is due to a similar change, though 
 arteriosclerosis is usually a factor also. Carbolic acid gangrene 
 (Fig. 18) results from the direct caustic action of the solution 
 employed, and often follows the use of a weak solution which 
 becomes concentrated by evaporation. 
 
 Bacteria are not a necessary accompaniment of gangrene; their 
 presence usually is incidental. In a few rare instances, bacterial 
 toxins are believed to be the immediate cause of gangrene by causing 
 endarteritis, phlebitis, and thrombosis. This is probably the case 
 in noma (p. 63). Emphysematous gangrene (p. 65) is due to infec- 
 tion with gas-producing bacteria, the production of gas preceding 
 the development of gangrene. Saprophytic bacteria usually invade 
 tissues which have already become gangrenous, and produce the 
 malodorous gases characteristic of putrefaction. 
 
 There are two main varieties of gangrene, the moisi and the dry, 
 dependent in large measure upon the amount of moisture in the 
 part when the vascular current is occluded, and on the amoimt of 
 evaporation which takes place. ]\Ioist gangrene usually is due to 
 venous obstruction (thrombosis, pressure of tumors, splints, bandages, 
 etc.); it is occasionally seen, however, after sudden occlusion of the 
 main artery of a limb (embolism, wounds, ligation, etc.), if the venous 
 blood already present remains in the part. Dry gangrene, of which 
 the senile form is typical, usually is due to slowly progressing arterial 
 occlusion, the parts deprived of vascular supply becoming mummi- 
 fied. Diabetic gangrene is usually rather dry. 
 
 Symptoms. — When a part which has been inflamed becomes gan- 
 grenous, the color fades into bluish green or purple, and finally into 
 black; the pain, at first burning and intolerable, suddenly ceases; 
 the affected area becomes numb and senseless; the cuticle is raised in 
 bullae filled with bloody or purulent fluid; the part instead of being 
 tense feels doughy; and the local temperature falls. There is gradually 
 formed, at the point where the resistive powers of the individual 
 are sufficient to overcome the destructive lesions producing the 
 gangrene, a line of demarcation, indicated by a red line encircling 
 the gangrenous structures. In this region the usual phenomena of 
 inflammation occur, and as this process continues, a line of granula- 
 tions is formed, known as the line of separation. By the gradual 
 increase of these granulations the dead tissues are pushed away, as 
 it were; and unless assisted by the surgeon this tedious process will 
 continue until the entire gangrenous area is extruded in the form of a 
 slough. An entire limb may be amputated spontaneously in this 
 way. 
 
 During the formation of the line of demarcation, there is often 
 considerable constitutional disturbance, due to the sapremia caused 
 by absorption from the imperfectly isolated gangrenous area; and 
 
TREATMENT OF GANGRENE 61 
 
 even during the process of gramilation, before the slough is cast off, 
 the patient is constantly exposed to infection from the decayed struc- 
 tures. These constitutional symi)toms usually are much less or 
 altogether absent in dry gangrene, where the process, as already 
 mentioned, resembles munnnification. 
 
 Treatment. — The separation of sloughs sometimes seems to be 
 hastened b\- poulticing the part. The charcoal poultice is particularly 
 useful in these cases, as it lessens the odor by absorbing tlie gases. 
 The yeast poultice also acts well. \ arious chemical digestants have 
 been used, in the eti'ort to aid nature in dissolving the sloughs; but 
 little more is thus accomplished than by simply kee{)ing the parts 
 clean and protecting them from outside infection. In the case of 
 extensive gangrene, tlie most important thing is to prevent infection; 
 amputation will surely be required later, but if infection is absent 
 the surgeon can safely postpone it until some indication is present 
 of the le^'el at which it must be done. Early amputation is often 
 needlessly high. In moist gangrene constant irrigation with dilute 
 antiseptics is one of the surest methods of preventing infection; in 
 dry gangrene it usually is sufficient to keep the parts well covered 
 with sterile cotton. Periodical baking of the limb, as in chronic 
 joint affections, is also of great service. In senile gangrene, where 
 only one or two toes are affected, formal amputation may never be 
 required, as nature will be able to remove the slough at one of the 
 phalangeal joints with less constitutional disturbance than w^ould be 
 caused by an operation ; if the gangrene extends beyond the toes, how- 
 ever, amputation should be done above the ankle; and if it extends 
 above the ankle, amputation through the lower third of the tbigli 
 should be done : it is not advisable to wait for the line of demarcation, 
 and to amputate at low^r points than those named almost certainly 
 would expose the patient to recurrence of gangrene in the stump. 
 To determine the level at w^hich amputation should be done Lejars 
 employs (1909) the "comparative hyperemia" test: the limb is 
 elevated, an elastic bandage is applied, exsanguinating it, and exsan- 
 guination is maintained by an Esmarch band for five or ten minutes 
 after the elastic bandage is removed; the hyperemic blush which 
 follows the removal of the Esmarch band will extend only so far 
 as healthy circulation is present, and amputation may be done safely 
 at this point. In the healthy limb the hyperemic blush extends to 
 the toes. Arterio-venous anastomosis (" reversal of the circulation") 
 as a method of treatment for gangrene, is discussed at p. 2-11. In 
 many cases of senile gangrene it is evident that any operation would 
 only hasten the fatal termination; under such circumstances of course 
 only palliative treatment is admissable. In diabetic gangrene (Fig. 19) 
 amputation is not to be recommended until sepsis threatens. De Witt 
 Stetten (1912) has shown .the remarkable success which attends 
 judicious conservative treatment, especially sterilization of the limb 
 by repeated baking. Amputation for gangrene following frost-bite 
 and bums, sht)uld not be done until the line of demarcation has 
 
62 
 
 DISEASES RESULTING FROM INFLAMMATION 
 
 formed, as it is impossible to know heforeliand at what le\'el the 
 limb must be removed. In the case of gangrene resulting from local 
 
 injury due to crushes, compound 
 fractures, etc., amputation should 
 be done as soon as gangrene is 
 manifest; it is impossible to pre- 
 vent infection in such cases, and 
 delay in resorting to amputation 
 usually will cost the patient his 
 life. When gangrene is due to 
 arterial occlusion (embolism, ligation 
 for wound), amputation should be 
 done at the site of the occlusion, 
 as soon as gangrene is evident 
 (Guthrie, 1815); but in the case 
 of injury to the superficial femoral 
 artery, amputation below the knee 
 usually is sufficient, and occasion- 
 ally in the upper extremity a 
 collateral circulation may be estab- 
 lished. 
 
 Special Forms of Gangrene. — 
 Decubitus or bed-sore (Fig. 21) is 
 due to necrosis of the skin and 
 subcutaneous tissues from long continued pressure on bony promi- 
 nences in those confined to bed, especially in those with debilitating 
 diseases or in a helpless condition. Favorite sites are over the sacrum 
 and sacro-iliac joints (Fig. 
 
 Fig. 19. — Diabetic gangrene. Aged 
 seventy-four years. Duration two 
 months. Healed under conservative 
 treatment. Episcopal Hospital. 
 
 re- 
 
 22); but any point 
 ceiving constant pressure 
 (occiput, scapulae, elbows, 
 heels, malleoli) may de- 
 velop bed-sores. They 
 usually may be prevented 
 by proper care of the skin, 
 allowing no folds or creases 
 in the bed-clothes (the pa- 
 tient may lie on a blanket 
 instead of a sheet), with 
 frequent changes of posi- 
 tion, and use of air-pillows, 
 rings, water-beds, etc. 
 Scrupulous cleanliness is 
 most important, keeping 
 the skin dry (in cases of 
 involuntary dejections) and protecting it after use of stimulating 
 lotions by dusting powders or soap plaster. The same measures are 
 important in the treatment of a bed-sore when once it has formed. 
 
 Fig. 20. — Dry gangrene from embolism; male, 
 aged forty years. In December embolus lodged in 
 brain, causing right-sided hemiplegia; in March 
 (three weeks before photograph) embolus lodged in 
 right popliteal artery. Death a few weeks later. 
 No operation. Episcopal Hospital. 
 
NOMA 
 
 63 
 
 TIk' sl(tui;li should iu»t \)v cut ;i\vii\' until it is (|uito loose, and tlic 
 undorlyiui;- ulcer should he dressiul with rather stinuilatiug- ointments. 
 Constitutional treatment never sliould l)e nefi;lected. (J<>t tlie patient 
 out of bed as soon as possible. Lon^jj continuance of a hirge bed-sore 
 is a tremendous drain on the vitality and not infrequently is an 
 indirect eause of death (exhaustion, sepsis, hemorrhage). 
 
 Fig. 21. — Decubitus or bed-sore, in a 
 patient, aged seventy-eight years; duration 
 two months. The sloughs have been cut 
 away. Episcopal Hospital. 
 
 Fig. 22. — Cicatrices from bed- 
 sores, in patient, aged twenty years, 
 developing during typhoid fever five 
 years ago. Episcopal Hospital. 
 
 Hospital Gangrene {Sloughing Phagedena, Pourriture cV Hopital). — 
 This scourge of military hospitals in former years probably is due to 
 a specific microbe. Its clinical causes are crowding, bad ventilation, 
 and generally unhj'gienic conditions. It is now almost unknown. 
 It arose only in wounds, though the wounds sometimes were mere 
 abrasions. The surface of the wound became dry, was covered with 
 "a pulpy, ashen slough," and the circular shape and cup-like depres- 
 sion of the wound were considered characteristic. By attention to 
 hygiene its development usually may be prevented. It is most 
 successfully treated by strong antiseptics (bromin, iodin) and scrupu- 
 lous cleanliness. Patients affected should be isolated. x'Ymputation 
 is scarcely ever necessary. 
 
 Noma. — Noma is a gangrenous affection, almost exclusiA'ely con- 
 fined to childhood, usually^ following the exanthemata (especially 
 measles) or typhoid fever. Various bacteria have been found by 
 different observers, certain forms of leptothrix being those most 
 frequently present. As mixed infection, including saprophytes, 
 almost always exists, the etiological relation of any one form is diffi- 
 cult to determine. The disease affects the mouth (Gangrenous 
 Stornatitis, Cancrum Oris) and the external genitals {Noma Pudendi), 
 especially the genitals of female children. The ear and the rectum 
 have also been affected. Whether in the mouth or the genitals, the 
 disease usuallv starts on the mucous membrane, and in an incrediblv 
 
64 
 
 DISEASES RESULT I XG FROM INFLAMMATION 
 
 short space of time, perhaps three or four hours, a gangrenous ulcer an 
 inch or more in diameter, may be i)resent. The first thing to attract 
 attention is often a shiny red spot on the exterior of the cheek, the 
 gangrenous ulcer having nearly perforated before being discovered. 
 But if this complication be kept in mind the disease may be detected 
 at an earlier stage from fetor of the breath, disinclination for food, 
 etc., which will lead the nurse or attending physician to examine 
 the mouth. The constitutional symptoms are slight, and the child, 
 though listless, may continue to play with its toys until the hour 
 of death. The alveolus may be involved, the cheek perforated, and 
 frightful destruction produced in a very short space of time. 
 
 Treat )ncnf should be prompt and vigorous; the child being anesthe- 
 tized, a mouth gag should be introduced, the cheek everted, scraped 
 
 with Volkmann's spoon, and 
 the base of the ulcer thoroughly 
 cauterized with fuming nitric 
 acid applied by a stout stick; 
 or acid nitrate of mercury may 
 be used. If the cheek has been 
 perforated, it is best to exer- 
 cise the whole ulcer; and it 
 may be necessary to excise a 
 couple of inches of the alveo- 
 lus (Fig. 23) . Free stimulation 
 must be employed afterwards 
 and the mouth kept constantly 
 clean by the use of suitable 
 washes. Death from exhaus- 
 tion, bronchopneumonia, or 
 pyemia, is the rule. The mor- 
 tality varies from 70 to. 95 per cent. If the child recovers, a plastic 
 operation may be necessary to restore the cheek. Similar treatment 
 should be adopted in the case of Noma Pudendi, which is a much 
 rarer affection. 
 
 Aiahum. — This is a rare tropical disease, generally ending in 
 gangrene, which usually is dry, affects the toes, and is almost exclu- 
 sively confined to the negro race. Unna, according to Freeman 
 (1906), regards it as a circular scleroderma which strangulates the 
 toe. The affected parts appear as if tightly constricted by a string, 
 and spontaneous amputation occurs after the lapse of an indefinite 
 time. The disease may extend over ten years. 
 
 Sjnnmetrical Gangrene. — Symmetrical gangrene is due to an obscure 
 affection of the nervous system (Raynaud's disease), causing local 
 asphyxia of symmetrical portions of the body, especially fingers 
 and toes, probably from \'ascular spasm. As a rule only small super- 
 ficial sloughs are formed. The symptoms are tingling, numbness, 
 etc. Intermittent claudication may be an early sign. Little can 
 be done in the way of treatment, except tonics and hygienic measures. 
 
 Fig. 2-3. — Xoma following inta.^lt.-, iw a 
 child, aged three years; duration one week. 
 The gangrenous parts have been excised. 
 Death. Children's Hospital. 
 
EMPHYSEMATOUS GANGRENE 65 
 
 Massage and hot baths, locally, may be of benefit. The patients 
 usually recover, though successive attacks are usual. Noesske (1909) 
 incises the finger tip down to the bone and applies a cupping glass; 
 his theory is that the gangrene is due to stagnation of blood from 
 venous obstruction; and that if a constant fresh su])ply of arterial 
 blood is obtained by cupping, gangrene may be prevented until the 
 spasm ceases. 
 
 Emphysematous Gangrene {Traumatic or Spreading Gangrene, 
 Gangrene Foudroyante). — Under this title three distinct affections 
 are sometimes grouped: (1) True empliysematous gangrene, a form 
 of gangrene due to infection with various gas-producing bacteria; 
 (2) JNIalignant Edema, caused by a specific bacillus; and (3) Ordinary 
 forms of gangrene, in which putrefactive changes are accompanied 
 by gas production. The third form clearly does not belong here; 
 but as the B. oedematic maligni is a gas-forming microbe, and as it 
 is usually impossible to distinguish clinically infection due to it from 
 that due to numerous other gas-forming microorganisms, there is no 
 good reason why it should not be included in this section. When 
 not due to the bacillus of malignant edema, emphysematous gangrene 
 may be caused by infection with the Bacillus aerogenes capsulatus, 
 B. proteus vulgaris, or B. coli communis, especially that first nanjied. 
 The condition is almost invariably observed only as a complication 
 of severe compound fractures or lacerated wounds, but occasionally 
 has followed punctured wounds or even mere abrasions. On the 
 third or fourth day after the injury the wounds do not discharge as 
 freely as might be expected, and careful palpation will detect emphy- 
 sematous crackling, which extends with alarming rapidity along 
 the subcutaneous tissues (especially along the course of the large 
 vessels), and may involve even the muscles. The skin becomes 
 dusky, purplish, and mottled in appearance, and at a later stage the 
 vesications and bullae, so characteristic of fermentative changes in 
 already mortified parts, may develop. Incisions into the swollen 
 and boggy tissues give exit to froth}'- fluid and malodorous gases. 
 The patient sinks into a typhoid state; there is little fever; the pulse 
 may be slow ; and death ensues a short time after the infection reaches 
 the .trunk. The entire course of the disease may extend over only 
 six or eight hours. The safest treatment is immediate amputation, 
 high above the limit of the affected tissues. When this is impos- 
 sible, free incisions should be made, the limb should be placed under 
 constant antiseptic irrigation, hydrogen peroxide being preferred as 
 the gas-forming bacteria are anaerobic; free stimulation should be 
 administered, and everything possible should be done to obviate the 
 tendency to a fatal termination. If amputation be done, the incisions 
 should pass through absolutely healthy tissues, and the stump should 
 be freely drained, and frequently dressed to detect the first evidence 
 of recurrence in the flaps. I have seen only two cases of emphy- 
 sematous gangrene: in the first case, under Dr. Neilson's care at the 
 Episcopal Hospital, it followed compound fracture of the elbow in 
 5 
 
66 DISEASES RESULTIXG FROM I X FLAM M ATI OX 
 
 an old man; the gangrenous emphysema invaded the chest in three 
 hours from its first appearance, before amputation could be done, 
 and death followed a few hours later. In the second patient (Fig. 24), 
 in Dr. Frazier's service at the Episcopal Hospital, a lad of sixteen, 
 whose arm had been caught in revolving rollers and the skin squeezed 
 off from above the elbow to the wrist, I successfully removed the 
 arm at the shoulder-joint (Fig. 163) a few hours after the emphysema 
 spread beyond the circular slough in the lower third of the arm. 
 
 Fig. 24. — Emphysematous gangrene. Recoverj- after amputation at the 
 shoulder-joint. Episcopal Hospital. 
 
 Cellulitis. — Cellulitis is the term used to describe inflammation 
 of the subcutaneous areolar tissue. This tissue, it is known, consists 
 essentially of lymph spaces lined by endothelial or connective tissue 
 cells; and it is now generally believed that these spaces have no 
 direct communication with the lymph vascular system. Certainly 
 cellulitis, as such, is clearly distinguished from lymphangeitis on the 
 one hand, and from infectious dermatitis on the other. The causes 
 are almost without exception bacterial infection, streptococcic rather 
 than staphylococcic, usually from some abrasion or lacerated wound; 
 but occasionally cellulitis, extending to the stage of suppuration, 
 follows a confusion, a .sprain, or a simple fracture, the infection in 
 
ERYSIPELAS 
 
 67 
 
 such cases hciii.u- c()n\-c\<'(l to the phicc of h'sscncd resistance through 
 the l)h)0(l-streain. ("elhihtis may also follow extravasaticMi of urine, 
 of hlood, etc. 
 
 Symptoms. — Tiie symptoms are those of inflammation, widely 
 dilfused heneath the skin, not in it, and characterized esi)ccially by 
 swellini;-. pitting on pressure, and the 
 al)sencc of marked redness (Fig. 25). 
 
 Treatment. — In the early stages rest 
 procured by splints, by the use of a sling, 
 by elevation of the part, together with 
 local anodyne (lead water and laudanum) 
 
 Fiu. 25. — Suppurative cellulitis of right forearm, 
 eleven day.s' duration. From infected wound of wrist. 
 Incised and drained through interosseous membrane. 
 Children's Hospital. 
 
 Fig. 20. — >Scar.^ from multi- 
 ple incisions for cellulitis of 
 calf. Episcopal Hospital. 
 
 and antiseptic (corrosive sublimate and alcohol) applications, may 
 suffice to eflfect a cure. As soon as evidences of suppuration occur, 
 the overlying skin should be incised, in as many places as may be 
 necessary, to give exit to pus, sloughs, etc. If the part affected is 
 very tense, as is frequently the case in the forearm and hand, it 
 is advisable to make free longitudinal incisions even before pus is 
 formed, as the relief of pressure will enable the body tissues to 
 combat the infection much more readily, and may prevent extensive 
 sloughing. Fig. 26 shows the scars of multiple incisions for cellulitis 
 of the leg. 
 
 Erysipelas. — Erysipelas (a word usually supposed to be derived 
 from two Greek words signifying red skin), known formerly as St. 
 Anthony's Fire, is a specific inflammation aft'ecting the skin, the 
 subcutaneous tissues, or both. Occasionally the mucous or serous 
 membranes are involved. It is a specific disease clinically; and 
 according to some authorities its cause, the Streptococcus erysipelatis 
 
G8 DISEASES RESULTING FROM INFLAMMATION 
 
 (Fehleisen, 1884), is specific, in the sense that it causes no other 
 disease; but equally good authorities maintain that it is not a 
 specific microbe, but merely a variety of the common streptococcus, 
 which for some unknown reason at certain times does not produce 
 the usual symptoms. The seat of the inflammation is the lymphatic 
 spaces of the skin itself (dermatitis) and of the subcutaneous tissues 
 (cellulitis.) 
 
 Erysipelas probably always is due to the presence of a solution 
 of continuity of the skin or mucous membrane, through which the 
 bacteria enter the tissues; but while it is not extremely rare in patients 
 with lacerated wounds and compound fractures, it arises much more 
 often as the so-called idiopathic variety, in which the wound probably 
 is some insignificant abrasion. Especially is this the case with facial 
 erysipelas, one of the most prevalent forms, the wound of entrance 
 being probably some excoriation of the nasal mucous membrane. 
 The eruption is characterized by its intense redness, which returns 
 immediately on the removal of pressure; by its glazed or shiny surface; 
 frequently by resicidation; by the raised, irregnlar, and well-defined 
 borders of the inflamed area; and by the erratic manner in which it 
 spreads (Plate I, Fig. 2). The inflammation is always most intense 
 at the periphery of the patch, while the centre may begin to fade 
 away very quickly. In simple erythema the patches have no ten- 
 dency to spread, their edges are not raised, and vesiculation is 
 unknown. In scarlatina the rash is not localized, it is neither 
 well defined nor are its margins elevated above the surrounding 
 skin; vesiculation is absent; it is a rare disease in adults; and a 
 history of contagion may be obtainable. The dermatitis resulting 
 from Rhits Toxicodendron is very difficult to distinguish from ery- 
 sipelas, except by the history; the same is true of saprophytic 
 dermatitis {erysipeloid of Rosenbach), due to local infection from 
 decaying fish, etc. In ordinary cellulitis the redness is less, and 
 the raised margins and vesicles of erysipelas are absent; and as the 
 skin itself is not involved in cellulitis the disease does not affect 
 the ears nor usually the skin over the tip of the nose, in which 
 situations subcutaneous tissue is practically absent. In erysipelas, 
 on the other hand, the pinna of the ear is prone to invasion. 
 
 Symptoms. — The subjective symptoms are marked: these are pain, 
 tingling, and a feeling of tension in the affected parts, which are 
 exquisitely tender; there is high fever, rapid pulse, furred tongue, 
 often delirium, and occasionally nausea, vomiting, and chills. As a 
 rule there are no prodromal symptoms of importance. The eruption 
 seldom lasts more than four days in one spot; from the original focus 
 it may wander irregularly over the body, or may break out in an 
 entirely different region. As the inflammation subsides, the skin 
 becomes brownish in hue, the vesicles dry in the form of scabs, and 
 the part appears more or less wrinkled. In facial erysipelas edema 
 is marked, the eyes being closed and the nose and ears swollen 
 
< 
 
TREATMENT OF ERVSIPELASi 69 
 
 beyond all recoffiiition. There is a tendency for the disease to spread 
 to the scalp; here the redness is less, anil the general <liaracteristics 
 of cellulitis are more evident. 
 
 Complications. In facial erysi])elas thiTC is always a danj^cr of 
 vttniiKjifis, from inxohcment of the angular \v'u\ or one of the 
 emissary veins of the skull. Nephritis may result from the strain 
 put upon the kidneys in the elimination of toxins. Endocarditis, 
 yhurisy, yncniuoma, ijeritonitis, arthritis, and general seyticemia 
 occasionally are o])served. Phlrgnionovs erysiyelas, so-called, is 
 streptococcic inflammation of the cellular tissues accompanying 
 erysipelas of the skin. If the erysipelatous inflammation invades 
 the fauces (angina), or the larynx, producing edema of the glottis, 
 laryngotomy may be necessary. 
 
 Prognosis. — Erysipelas is a serious disease, though seldom the 
 direct cause of death. S. Erdman (1913) gives the hospital mor- 
 tality as 11 per cent. One attack seems to predispose the patient to 
 recurrence. 
 
 Treatment. — When occurring in a hospital ward, cases of erysipelas 
 should be isolated; for although contagion through the air has not 
 been known to occur, the infection of other patients by contact 
 cannot always be prevented. The surgeon who dresses the wounds 
 of an erysipelatous patient should not practice obstetrics while so 
 engaged. O. \Y. Holmes (1843) long ago called attention to the 
 relation between erysipelas and puerperal fever. Constitutional 
 treatment is to be given only as indicated; stimulants and tonics, 
 especially the tincture of the chloride of iron or quinin, are usually 
 of benefit; a purge at the onset of the attack may do much to hasten 
 its disappearance. In the way of local treatment very little can 
 be done that is really productive of any marked benefit. Ichthyol 
 ointment has been much used, and is agreeable to the patient. A 
 saturated solution of magnesium sulphate is claimed by some 
 (Tucker, 1908) to have almost magical power in dispelling the 
 eruption; the parts affected should be covered with gauze wrung 
 out of and kept constantly wet w4th the solution. Apart from its 
 well-known local anesthetic action, I have not myself observed any 
 marked advantages in the use of magnesium sulphate. Painting 
 the skin with collodion, iodin, or strong solutions of silver nitrate 
 (33 per cent.), about an inch beyond the margin of the erysipelatous 
 patch, has in some cases appeared to be of value in limiting the march 
 of the infection; but when it is remembered that the dermatitis 
 usually subsides of itself in about four days, it is seen that no remedy 
 can be said to be specific. When the subcutaneous tissue is affected, 
 the treatment is the same as for cellulitis, but incisions are to be 
 emplo^-ed even earlier, owing to the greater intensity of the inflam- 
 mation. Anti-streptococcus serum is harmless, and if possible should 
 be administered in all severe cases. Erdman gave vaccines an extended 
 trial and concluded that they were useless. 
 
70 
 
 DISEASES RESULTINCj FROM INFLAMMATION 
 
 GENERAL AFFECTIONS RESULTING FROM INFLAMMATION. 
 
 In addition to the local reaction to injury, which has been studied 
 in Chapter I under the heading of Inflammation, there is also a 
 reaction by the organism as a whole. In even the simplest cases 
 the local reaction is accompanied by more or less constitutional 
 disturbance, evidenced chiefly by fever, by which term I think, with 
 Adami, it is convenient to designate this condition, whether or not 
 it is attended by elevation of temperature {pyrexia). Not only will 
 many aseptic operations be followed by this so-called aseptic fever 
 (Genzmer and Volkmann, 1877), but some patients on whom no 
 
 operation has been done (simple fractures, 
 etc.), also will have a slight rise of tem- 
 perature and other signs of fever on the 
 first day or two following the injury (Fig. 
 27). In most cases the temperature does 
 not exceed 100° F., and if it goes beyond 
 101° F. after an operation it is very prob- 
 able that infection is present. Yet in one 
 case of arthrodesis, under my care at the 
 Orthopedic Hospital, the temperature rose 
 to over 102° F. on the second day, but 
 the wounds pursued a perfectly aseptic 
 course. The cause of the aseptic fever 
 was formerly ascribed to the liberation of 
 fibrin ferment in the circulation, due to 
 thrombotic changes and phagocytic action 
 at the seat of injury; but more modern investigations tend to show 
 that it is due to the liberation of nucleins and albumoses. It is not 
 impossible that the cocci normally found in the deeper layers of 
 the skin may be at fault, and that the fever is really not aseptic 
 in the strict sense of the word. No special treatment is required; 
 the symptoms subside spontaneously in a day or so. A laxative 
 usually is beneficial. 
 
 Sepsis.^ — When bacteria or their products enter the circulation, 
 there is developed the condition known as sepsis. If the products 
 of pathogenic bacteria enter the circulation, but the bacteria them- 
 selves remain in the tissues at the seat of primary infection, the 
 condition is named toxemia; this is to be distinguished from intoxi- 
 cation, the condition due to poisoning by non-bacterial products 
 (drugs, products of perverted metabolism, etc.). Diphtheria and 
 tetanus are typical examples of toxemia. If the bacteria themselves 
 are present in the circulating blood, the condition is termed bac- 
 teriemia; typhoid fever is a typical bacteriemia, the bacilli circulating 
 
 Fig. 27. — Temperature chart 
 of aseptic fever ; contusion of hip ; 
 aged sixty-four years. Episcopal 
 Hospital. 
 
 ' The terminology employed by writers in describing the conditions named 
 below is by no means uniform. I have adopted the designations which have 
 seemed to me, after considerable study, to be most characteristic of the maladies 
 named, and least confusing to the student. 
 
SEPTICEMIA 71 
 
 l'rr('l\ in the blood, and producin<f tlic wcll-kiiow ii roscohir ('ni])li()ii 
 hy lodifinjic in tlie skin. If tlic hattcriii whicli circulate in the l)h)0(i 
 are hij^hly pathoj^enic, as the streptococcus or staphyhx-occus, the 
 condition is properly denominated septicemia; hut tiiis term is 
 frequently used negligently to describe any form of sepsis whatever. 
 If the bacteria circulating in the blood lodge in various parts of the 
 body, forming nniltiple abscesses, the disease is named pyemia. 
 Under the name sarco-sepsis, Lockwood (1896) described a septic 
 condition due to the presence of bacteria in the tissues, but not in 
 the circulating blood; but as it is impossible to distinguish this con- 
 dition from toxemia or septicemia during life, and as it is doubtful 
 whether septic symptoms are produced })y l)acteria in the extra- 
 vascular tissues, except through the entrance into the blood of 
 bacterial toxins (toxemia) or the bacteria themselves (bacteriemia, 
 septicemia), it seems undesirable to complicate the study of sepsis 
 by discussing this condition further. Finally, if the constitutional 
 symptoms are due to absorption of products of saprophytic (non- 
 pathogenic) bacteria, the patient is said to be suffering from sapremia. 
 
 Toxemia. — This is the condition formerly described as inflammatory, 
 traumatic, surgical, sympathetic, or symjjtoinatic fever. As modern 
 methods of clinical study have developed, it has been found that 
 this condition may be distinguished from aseptic fever; and at the 
 present day it is usually the latter that is meant, when reference is 
 made to inflammatory or surgical fever. For the development of 
 toxemia it is necessary for bacteria to be present, and they are rarely 
 present without open wound; but in cases of intestinal obstruction, 
 and in infective diseases of internal organs (appendicitis, cholecys- 
 titis, pyelitis) it is the rule for toxemia to exist. If no focus of 
 infection can be discovered, the sepsis is said to be cryptogenetic. 
 The presence in the blood of bacterial toxins causes the usual 
 constitutional symptoms of inflammation, which have already been 
 detailed (p. 31). Traumatic delirium (p. 175) is probably due to 
 toxemia. If the aseptic fever customarily seen after an operation 
 does not subside in two or three days, it is probable that some septic 
 focus exists; and if this is not promptly relieved by drainage, the 
 aseptic fever will become septic in nature, and the patient will suffer 
 from toxemia, the commonest form of sepsis. 
 
 Treatment. — The treatment consists in removing the cause of 
 infection when this is possible, and in thoroughly draining the infected 
 area when entire removal is impossible or inexpedient. Plenty of 
 water should be introduced into the system, either by mouth, or by 
 the use of saline solution intravenously or by hypodermoclysis or 
 proctoclysis. If the toxemia is known to be due to a specific cause 
 (tetanus bacillus, colon bacillus), antitoxic serum should be adminis- 
 tered; and even in the case of the common infections (streptococcus, 
 staphylococcus), antitoxic serum occasionally is of benefit. 
 
 Septicemia. — Septicemia, which is the commonest form of 
 bacteriemia seen by surgeons, is distinguished at its onset from 
 
72 
 
 DISEASES RESULTING FROM INFLAMMATION 
 
 toxemia by no very well recognized symptoms. The febrile symptoms 
 (pyrexia, anorexia, delirium, etc.) are all more pronounced; septic 
 diarrhea may take the place of constii)ation, and intestinal or other 
 internal hemorrhages may occur (Cf. "critical discharges," p. 31). 
 Chilly sensations or an actual chill may occur early in the disease, 
 perhaps due, as suggested by Adami and others, to relatively high 
 temperature of the central nervous system. The temperature usually 
 is not very high (100° to 102° F.). The pulse is rapid and feeble, 
 and no drugs have power to reduce its rate; it becomes more and 
 more rapid, and progressively weaker until death, which is the usual 
 termination of surgical septicemia (Fig. 28). In some patients who 
 have seemed to do well after evacuation of septic foci, rapid death 
 occurs from so-called terminal infection (Fig. 29). Clinically speak- 
 ing, it is usually impossible to distinguish between toxemia and 
 
 DAY OF 
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 rN?H28 29 30 31 1 
 
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 RESP. ^i 1 ?! ?! s? ?3 
 
 Fig. 28. — Puerperal septicemia; death. 
 Episcopal Hospital. 
 
 Fig. 29. — Diffuse purulent peritonitis from 
 appendicitis. Death from terminal infec- 
 tion (residual abscess). Episcopal Hospital. 
 
 septicemia, except that the latter is little influenced by treatment. 
 Sometimes by blood cultures it is possible to ascertain the presence 
 of bacteria in the circulating blood during life; but as the number 
 present in the blood may be few, a sterile culture is usually no proof 
 that bacteriemia does not exist. The presence of staphylococcus 
 albus in the culture usually is due to contamination from the skin. 
 Treatment.^ — Treatment of septicemia, as already indicated, usually 
 is impotent to stay the course of the disease. As pointed out by 
 Lockwood (1896), at autopsy the bacteria are found even in the 
 coronary arteries of the heart, and the persistent rapidity of the 
 pulse may thus be accounted for. Nevertheless, as the diagnosis 
 is sometimes impossible, except at autopsy, all the measures sug- 
 gested for the treatment of toxemia should be employed in these 
 cases, and it is possible that, in some patients, life may be saved. 
 
PYEMIA 
 
 73 
 
 Park speaks favorahly of the use of rngnenUnn Crede, which is 
 absorbed through tlie skin; and he tliinks benefit is derived from 
 "tlie dissemination througliout the system of the antiseptic virtues 
 of tlie silver itself." He also connnends the intravenous use of a 
 solution of Crede's soluble silver (1 gram of silver in 1000 c.c. of 
 water). Barrows has used formalin solution (1 to 5000) intra- 
 venously with alleged benefit. 
 
 Pyemia. — Nearly invariably this is associated with thrombosis and 
 embi)lism (p. 237). A portion (embuhis) of the septic clot or a clump 
 of bacteria from the original focus of infection becomes detached, 
 and is transported in the blood stream to the nearest set of capil- 
 laries, where it lodges (embolism). Once lodged, the bacteria present 
 in the embolus produce suppuration in the new location, and a 
 secondary or metastatic abscess is formed. The primary thrombus 
 
 Fig. 30. — Temperature chart in pyemia; acute osteomyelitis of calcaneum; 
 abscess of brain; death. Episcopal Hospital. 
 
 usually is venous in location, and the detached clot naturally might 
 be expected to be arrested in the pulmonary circulation; but for 
 some reason this is not always the case, the embolus passing safely 
 through the lungs and being arrested first bj' some portion of the 
 systemic capillary network. Occasionally, when the embolus first 
 is carried into the venous current it travels against the usual course 
 of the blood, and lodges in some portion of the venous channels 
 distal to the primary lesion. This process is known as retrograde 
 embolism; it may occur in suppurations in the neighborhood of the 
 vena cava, or in the face, the blood current in the angular artery 
 flowing sometimes toward the brain and sometimes outward. If 
 the primary lesion is in the distribution of the portal vein {e. g., the 
 appendix), the first set of capillaries encountered by the embolus 
 will be the hepatic, and multiple liver abscesses will result. When 
 
74 
 
 DISEASES RESULTING FROM INFLAMMATION 
 
 in the systemic circulation, many different regions and organs may 
 become affected; metastatic abscesses in the subcutaneous tissues 
 or joints are most easily detected; but those in the kidneys, spleen, 
 liver, lungs, or brain sometimes may be diagnosed during life. 
 The original focus may be any supjjurating or septic lesion. Burned 
 surfaces and suppurative lesions of bone are among the commonest 
 causative conditions. 
 
 Symptoms. — The symptoms are those of septicemia, with certain 
 important modifications. The temperature is typically irregular"; 
 its variations are extreme, and the absence of jjeriodicity is charac- 
 teristic (Fig. 30). The highest temperature (104° to 106° F. or higher) 
 on one day may be at a certain hour in the afternoon, whereas the 
 next day the temperature may reach its highest point in the morning 
 or not until late at night; or hyperpyrexia may be absent for an 
 entire day or so. Chills are frequent, immediately preceding the fall 
 of temperature, and are often indicative of the lodgement of an 
 embolus, which may be attended by sudden pain. 
 
 DAY OP 
 MONTH 
 
 25 
 
 2(i 
 
 
 21 
 
 
 
 28 
 
 
 29 
 
 104 
 .103 
 
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 slOO 
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 »l lsl ls| |si 
 
 s 
 
 g 
 
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 Fig. 31. 
 
 -Sapremia; rapid fall of temperature after evacuation of retained secundines. 
 Episcopal Hospital. 
 
 Prognosis. — The prognosis is extremely bad; a few patients, in 
 whom the infection seems to be attenuated and the course of the 
 disease chronic, occasionally recover. The staphylococcus is more 
 frequently the causative organism than the streptococcus. 
 
 Treatment. — Treatment is the same as for septicemia. Constant 
 vigilance is needed to detect and locate metastatic abscesses, and 
 they should be drained immediately, when accessible; and unless 
 the patient is so ill that a formal operation will hasten his death, 
 the surgeon should not hesitate to evacuate abscesses of the internal 
 organs or even the brain. By ligating or excising the main venous 
 trunks leading from the original lesion, the infection sometimes 
 may be successfully localized (internal jugular in mastoiditis, ovarian 
 in parametritis, angular in facial phlegmon, etc.). 
 
SAPREMIA 
 
 75 
 
 Sapremia. W'Iumi dead or dying tissue is in contact with li\ing 
 cells, the jjtoinains and other ))oisons elaborated by the saprophytic 
 bacteria which infest the former may be absorbed into the i)atient's 
 body, and thus produce the usual syni])tonis of toxemia. When 
 healinji; in the wounded area has j)rogressed to the stage of granu- 
 lation, little if any absorption occurs; but injudicious probing of a 
 gramilating wound may destroy this barrier, and evidences of sepsis 
 will follow. It is sometimes imjxjssible to distinguish mild grades 
 of sapremia from asei)tic fever, or from a slight toxemia due to 
 absorption of the products of pathogenic bacteria; but usually it is 
 easy to differentiate clinically between sapremia and toxemia, because 
 
 2 3 4 5 *i 7 8 9 10 II 12 13 14 15 10 17 i% 1!) 20 21 22|23l24 25 
 
 Fig. 32. — Tuberculosis of hip; hectic temperature arrested by excision of hip. 
 Orthopsedic Hospital. 
 
 in the former case there always is some dead and decaying tissue 
 present, where the putrefactive bacteria multiply. If this material 
 is removed, the bacteria are removed with it, absorption ceases, 
 and health is restored. Sapremia is seen in its typical form in puer- 
 peral cases, absorption occurring from the retained secundines (Fig. 
 31). Hectic fever, which is classed by Park as chronic sapremia, is 
 most typical in patients wdth tuberculous bone disease, where siruises 
 exist, and as a consequence the decaying bone has become infested 
 with saprophytic bacteria. Fig. 32, from a patient with coxalgia 
 under my care at the Orthopedic Hospital, in the service of Dr. 
 Harte, shows hectic fever promptly arrested by excision of the hip. 
 
CHAPTER III. 
 
 MODIFIED FORMS OF INFLAMMATION (SURGICAL 
 INFECTIONS). 
 
 Situated pathologically half way between pure inflammation 
 and neoplasms, exists a group of surgical diseases usually described 
 as the infections gramdornas. This term implies that although the 
 lesions are definitely known to be caused by speciiic microorganisms 
 (which is not the case with tumors), yet the tissue reaction to these 
 specific irritants is characterized rather by cell accumulation than by 
 actual destruction of tissue by suppuration. It is as if the irritant 
 were too timid to provoke vigorous resistance, yet too enduring to 
 be overcome at the first onslaught; the tissues of the body seem 
 either indifferent to the invasion, or unable to continue the struggle 
 with the success which usually attends their warfare in acute inflam- 
 mation. While the more important of these modified forms of inflam- 
 mation (Tuberculosis, Syphilis, Actinomycosis) partake of the nature 
 of subacute or chronic reactions, there are others (Anthrax, Glanders, 
 Tetanus, Hydrophobia) in which the reaction is acute, and the lesions 
 less circumscribed, but which it is nevertheless convenient to discuss 
 in the same chapter. 
 
 CHRONIC INFECTIOUS SURGICAL DISEASES. 
 
 Tuberculosis. — Surgical tuberculosis includes all manifestations of 
 this infection, wherever situated, which are amenable to surgical 
 treatment. The specific cause of the disease, the B. tuberculosis 
 (Koch, 1882), gains entrance to the body usually through the digestive 
 or the respiratory tract. It has been held by good authorities that the 
 bacilli may pass through the respiratory or intestinal mucosa and 
 produce no lesions in it. The bacilli lodge most frequently in the 
 lung; next most frequently in the lymphatic nodes — cervical, bronchial, 
 or mesenteric. Occasionally infection occurs through an open wound; 
 inoculation with tuberculous material while dissecting produces the 
 so-called anatomical tubercle. 
 
 The bacillus is omnipresent in civilized life, and it is by no means 
 improbable that it lives as a parasite in the bodies of most apparently 
 healthy persons. It is always at hand to attack any place of lessened 
 resistance, and to explain its prompt appearance in such locations 
 it is usually necessary to assume that it was present previously, though 
 latent, somewhere in the patient's body. Scrofula, formerly con- 
 sidered a distinct disease, is now generally recognized as identical 
 
SURGICAL TUBERCULOSIS 11 
 
 with tuberculosis; it is, liowover, as DaCosta says, a useful term to 
 describe the habit of body of such as are easily infected with tubercu- 
 losis; in other words, scrofula may be considered tuberculosis in its 
 primary, latent state. 
 
 Tuberculosis is most often i)rimary in the lungs, digestive tract, 
 lymph nodes, urinary and sexual organs, and the bones. Surgical 
 tuberculosis, which is said usually to be secondary to an inconspicuous 
 lesion of the lungs, is seen especially in the lymph nodes, the bones 
 and joints, the sexual organs, peritoneum, etc.^ 
 
 Pathology. — The local lesion produced by the B. tuberculosis is 
 called a iuhcrde; its proper adjective is tnhercidous ; and it should be 
 distinguished from a tubercule, a term which describes the anatomical 
 form of the lesion of a skin eruption which is called tubercular, but 
 which is in no way connected with tuberculosis. When the B. tuber- 
 culosis begins to proliferate in the tissues, its first effect is to exert 
 chemotactic action upon the connective tissue and endothelial cells 
 in its immediate vicinity. It does not exert positive chemotaxis upon 
 the leukocytes circulating in the blood, and leukopenia not leukocy- 
 tosis is the rule; but the number of circulating lymphocytes may be 
 relatively increased. Locally, as the tissue cells accumulate, their 
 appearance changes, the cells swell up, become pale, and resemble 
 epithelial cells so closely that they are widely known as epithelioid 
 cells. This accumulation of epithelioid cells around the tubercle 
 bacilli causes an anemia of the central area, and the epithelioid cells 
 themselves gradualh' suffer from lack of nourishment, and, instead 
 of actively dividing and multiplying their number as at first, they 
 seem to be unable to carry the process of reproduction further than 
 the stage of division of the nuclei; so that among the epithelioid cells 
 there soon appear two, three, or more large cells with multiple nuclei, 
 arranged around the periphery or at the two poles of the cell— the 
 so-called giant cells. In the area immediately surrounding the giant 
 cells and epithelioid cells, the lymphocytes accumulate; while the 
 centre of the tubercle is composed of tissue and cellular debris under- 
 going caseous degeneration, which is the form of anemic necrosis 
 particularly characteristic of tuberculosis. Some phagocytosis exists, 
 but it sometimes seems as if the tubercle bacilli continued their exist- 
 ence as parasites even within the cell bodies of their victim: they are 
 most apt to be seen within the giant cells; they are frequently present 
 in the epithelioid cells; but are said never to be found within the 
 lymphocytes. The histological tubercle, thus, maj' be represented 
 diagrammatically (Fig. 33) as composed of three portions: (1) a cen- 
 tral caseous or necrotic area, in which may be a giant cell, its own 
 centre showing commencing caseation; (2) the epithelioid cells sur- 
 rounding the caseous centre, and (3) the peripheral aggregation of 
 lymphocytes. 
 
 * Some modern investigators believe that the bovine form of Tubercle bacillus 
 is responsible for "surgical tuberculosis," while the human form is that usually 
 found in the lungs. 
 
78 
 
 CHRONIC INFECTIOUS SURGICAL DISEASES 
 
 The products of the tul)ercle bacillus, spoken of generically as 
 tuberculin, are not very well understood; it seems probable, never- 
 theless, that caseation is induced by the toxins set free from the 
 bodies of the bacilli when they die, but that the irritant action of the 
 living bacilli is only sufficient to provoke cell accumulation and multi- 
 plication. These various products of tubercle ])acilli usually exist 
 in greater or less amount in the body fluids and excretions of animals 
 suffering with tuberculosis; and, when injected into other animals 
 afflicted with tuberculosis, the tuberculin contained in them produces 
 a characteristic reaction which may be used for the purpose of diag- 
 nosis- (p. 81). 
 
 Fig. 33. — Section through a tubercle. Upon the margin of the tubercle lymphoid cells 
 may be seen; in the centre epithelioid cells and a giant cell. (Lexer-Bevan.) 
 
 The primary tubercle may be replaced by granulation tissue formed 
 from the surrounding connective tissue cells, and healing may occur 
 in a manner similar to that of simple inflammation. Or the "pyogenic 
 membrane" may isolate and encapsulate the tubercle, and thus the 
 disease may be arrested; calcification is a frequent sequel. On the 
 other hand, some of the bacilli may escape through the cordon of 
 epithelioid cells on guard, and, settling in a neighboring portion of 
 the tissues, they may there proceed to form a new tubercle; and as 
 many more tubercles are formed, the area may become visible to the 
 naked eye, and the centre of the entire mass may be seen as a caseous 
 nodule surrounded by comparatively healthy tissue (Fig. 34). Two 
 
S VRCKW L T [ BER( ' l' LOS IS 
 
 79 
 
 processes may thus be initiated — either productive or dejjenerativc; 
 the former gives rise to tiil)crculi>n.s (fun (/on ft) ij;ran illation tissue, fre- 
 quently descril)ed as the tuberculous gumma (Figs. 35 and 37), because 
 
 .V 
 
 M 
 
 ^.>.^^...::^ 
 
 Fig. 34. — Cross-section of tuberculous testicle, showing areas of caseation. Skin 
 adherent. One sinus has been divided in the section. From a patient in the Episcopal 
 Hospital. 
 
 it is very difficult to distinguish it histologically from the gummas of 
 syphilis, actinomycosis, etc.; whereas the degenerative changes result 
 in the formation of a cold abscess, so named to distinguish it from the 
 
 Fig. .35. — Tuberculous gummas of leg, in a baby, aged eight months. 
 Children's Hospital. 
 
 ordinary abscess of inflammation, which is characterized })y its heat. 
 Tuberculous granulation tissue has a great tendency to displace all 
 normal tissues with which it comes in contact: in bones it causes the 
 
80 
 
 CHRONIC INFECTIOUS SURGICAL DISEASES 
 
 disappearance of the normal osseous structure; in joints it grows upon 
 the synovial membranes, producing fibrous ankylosis; in tendon 
 sheaths it spreads along their course, gradually invading the tendons 
 and in time causing their entire disappearance. The degenerative 
 changes, which by the process of coagulation and liquefaction necrosis 
 change tuberculous granulation tissue into cold abscesses, are probably 
 due, as already pointed out, to excessive destruction of tubercle 
 bacilli with liberation of their endotoxins, and to the action of fer- 
 ments set free by the death of cellular protoplasm. When the cheesy 
 pus finds an exit for itself, the tuberculous abscess is converted into 
 a tuberculous sinus, or if the walls of the abscess cavity are unable 
 to collapse, as in bone, and often in the lungs, a tuberculous cavity 
 remains. As the tuberculous sinus heals, it becomes converted into a 
 
 ^^^KtSitmSk-^^ 
 
 ^<rt ^^H 
 
 
 J 
 
 
 1 ^ 
 
 f >-\ 
 
 t-i 
 
 Fig. 36. — Scrofulous ulcers, one month Fig. 37. — Tuberculous dactylitis(tuber- 
 
 duration. Two months after incomplete culous gummas of fingers). Children's 
 
 operation for recurrent tuberculous cervical Hospital, 
 adenitis. Episcopal Hospital. 
 
 tuberculous ulcer (Fig. 36). It w^as once hoped that by the admin- 
 istration of tuberculin to tuberculous patients their tuberculous lesions 
 could be disintegrated and caused to discharge; but, unfortunately, 
 it has been found that sudden disintegration of tuberculous foci is 
 more apt to be followed by acute generalized miliary tuberculosis, 
 which may be succinctly described as tuberculous pyemia. Any 
 secondary infection, moreover, of a tuberculous focus, is prone to 
 aggravate the condition by weakening the protective layer of epithe- 
 lioid and lymphoid cells which surround the tuberculous area. The 
 great danger when any cold abscess discharges is that of secondary 
 (pyogenic) infection. As Calot says, the opening of a cold abscess 
 is the opening of a door by which death soon enters. 
 
 Diagnosis. — The detection of the tubercle bacillus in the lesions 
 renders the diagnosis certain; but in the vast majority of cases this 
 
SURGICAL TUBERCULOSIS 81 
 
 is not rociiiisite, as the clinical appearances are quite sufficient to 
 justify the diagnosis of tuberculosis. The indolence of the reaction, 
 the slow course of the disease; the characteristic cheesy material 
 discharged from the sinuses; the absence of leukocytosis in uncom- 
 plicated cases; and the general ai)pearance of the patient; these all, 
 when conibiiu'd in one indi\idual, make the actual detection of the 
 tubercle bacillus an unnecessary task in most cases of external tuber- 
 culosis (bones, joints, lymph nodes, skin, etc.). In tuberculosis of 
 certain internal organs, especially the kidney, it is highly desirable 
 to detect the bacilli in the excretions. Another aid to diagnosis is 
 the titherculin test (p. 78) : old tuberculin^ is that generally used, 
 the initial dose in adults being one-tenth of a milligramme (0.0001 
 gramme) hypodermically; this rhay be increased at subsequent injec- 
 tions to 1 and even to 5 milligrammes. The hyi)odermic use of tuber- 
 culin gives reasonably accurate results, and I prefer this method to the 
 conjunctival test of Calmette, or to the inunction of jMoro's tuberculin 
 ointment. The cutaneous reaction of v. Pirquet is usually to be 
 preferred in children (under twelve years of age), but as it appears 
 to indicate the existence of latent or healed tuberculosis (very rare 
 in children) quite as readily as an active focus, it is not regarded as 
 so accurate as the hypodermic test for adults. The hypodermic test, 
 unless repeated, causes reaction only when there is an active focus in 
 the body; but it does not necessarily indicate that the lesion suspected 
 is tuberculous. If, however, its use causes an exacerbation of symp- 
 toms in the suspected lesion {focal reaction) there can be very little 
 doubt of its tuberculous character. After the hypodermic injection 
 has been given, the patient's temperature should be recorded every 
 two hours for a period of 24 hours: a positive reaction, indicating the 
 presence of tuberculosis, consists in an abrupt rise of temperature to 
 101° or 102° F., occurring usually about the twenty-second hour.- 
 Sometimes a chilly sensation is experienced as the temperature 
 begins to rise. If the first injection is negative, a second and even 
 a third may be given, gradually increasing the dose. I have 
 never seen any untoward result. The reaction is positive in most 
 cases of tuberculosis not in advanced stages; it is usually negative 
 when secondary infection is present, with amyloid changes in the 
 viscera and a hectic temperature; but in such cases the diagnosis is 
 easy enough without this test. Indeed it is quite useless to employ 
 a tuberculin test if the diagnosis can be made clinically. In v. Pir- 
 quet's method three small areas on the arm are abraded, and into 
 
 ^ Old tuberculin is a filtrate of a concentrated glycerin extract of tubercle bacilli; 
 it is possible that some of the bacilh may not be excluded by the filter; to obviate 
 this danger Koch has prepared two new tuberculins: of these Tuberculin Oberst 
 (T. O.) is the supernatant liquid obtained by centrtfugalization of a concentrated 
 glycerin extract of tubercle bacilli; the sediment which forms, containing the bacilli 
 themselves, is ground up and again centrifugalized, and forms Tuberculin Rest 
 (T. R.). T. O. resembles old tubercuhn, and may be used instead of it in diagnosis; 
 T. R. is used in treatment. 
 
 2 An earlier rise, especially within a few hours of the injection, probably is 
 due to some contamination. 
 6 
 
82 CHRONIC INFECTIOUS SURGICAL DISEASES 
 
 one or two of these the tubercuUn is rubhed; the other abrasions 
 being used as controls. On the second or third day, in tul)ercu- 
 lous cases, the infected area shows a characteristic, erythematous, 
 papular, and even vesicular eruption. 
 
 Treatment. — Constitutional and hygienic treatment are quite as 
 imi)ortant in surgical as in medical tuberculosis. The majority of 
 patients with surgical tuberculosis are children of a school-going 
 age. It is better for them to give up school for one or two years, 
 until their constitution is strong enough for them to conquer the dis- 
 ease, than to attempt to keep up in their classes and grow physically 
 worse and worse. It may not be possible for them to sleep in the 
 open air, but they can at least sleep with all the windows in their 
 room open, and be out of doors as much as possible during the day. 
 In hospitals provided with suitable roof-gardens, where the patients 
 may be kept in the open air practically twenty-four hours out of the 
 twenty-four, it has been found that operative treatment is scarcely 
 ever-required. In institutions where it is impossible for one reason 
 or another to keep the bed-ridden patients out of doors constantly, 
 it usually is quite possible for their beds to be wheeled out of doors 
 and left out from 7 a.m to 7 p.m. It is by no means necessary to have 
 a hospital in the country for these patients: porches and balconies, 
 even if roof-gardens cannot be obtained, will accomplish the same 
 results in the most thickly settled parts of the city. Hand in hand 
 with the open air treatment must go full, wholesome diet, especially 
 milk and eggs; and the only medicine usually required is cod liver 
 oil, which seems to act better than any otiier remedy in increasing 
 the appetite and causing the patients to put on flesh. In the rare 
 cases where it does not do good, the syrup of the iodide of iron, the 
 compound syrup of the hypophosphites, or other remedies, may be 
 tried. 
 
 Locally, I am convinced that tuberculosis of the soft parts demands 
 a different treatment from that of bone. In the latter case such re- 
 markable results are obtained in children by local rest, without opera- 
 tive interference, that I am extremely conservative in urging any 
 other surgical treatment: the use of plaster casts, braces, weight 
 extension in bed, together with proper hygienic treatment, will cure 
 nearly all patients in whom these methods are adopted early. As 
 regards tuberculosis of the soft parts (lymph nodes, generative and 
 urinary organs, peritoneum), however, local rest is usually impossible 
 to secure, and I feel sure that better results are obtained ])y radical 
 operation, removing the entire disease; and when this is impossible, 
 as in the abdomen, at least remoA'ing the primary focus. The local 
 treatment adapted to each form of tuberculosis will be pointed out 
 when the surgery of those portions of the body is discussed. 
 
 Syphilis. — This is an infectious granuloma due to inoculation with 
 the Treponema pallidum {Spiruchata pallida), a parasite described by 
 Schaudinn and Hoffman (1905), and obtained in pure culture iii 1911 
 by Xoguchi and by Hoffmann. 
 
PATHOLOGY OF SYPHILIS 
 
 S3 
 
 Pathology. — This organism usually gains access to the tissues 
 through sonic abrasion or excoriation of the skin or mucous mem- 
 branes, being inoculatecl directly from a sore in another person sull'cr- 
 ing from syphilis {'uiniicdiatc cunfaffiun). Occasionally vicdiaic con- 
 tagion occurs, the virus being transmitted by means of soiled towels, 
 eating and drinking utensils, etc. When inoculated, there follows a 
 period of inruhaiion, averaging from three to five weeks, during which 
 the microbes multii)ly at the site of primary in\asion, and are carried 
 by the lymi)h channels to the nearest lymph nodes; so that by the 
 time the local reaction appears at the site of original inoculation, the 
 disease is already diffused in the patient's body. Neisser found the 
 blood contained the virus as 
 early as the fifth day after 
 inoculation. The local reac- 
 tion (chancre) resembles the 
 tubercle in some ways: a col- 
 lection of round cells occurs, 
 and there may be a few giant 
 cells present; but the chancre 
 is particularly characterized 
 by the great proliferation of 
 the endothelial cells lining the 
 capillaries. By proper stain- 
 ing methods the presence of 
 the Treponema pallidum may 
 be demonstrated; otherwise 
 the histological picture is not 
 regarded as conclusive, though 
 endothelial proliferation is 
 always suggestive of a syi)hi- 
 litic lesion. 
 
 The chancre is situated in the true skin (derma) ; usually when first 
 seen, exfoliation of the overlying epidermis has occurred, converting 
 the primary lesion into a superficial erosion; in some cases the local 
 reaction is much more marked, and the deep or Ilunterian chancre 
 develops. Usually very soon after the appearance of the chancre, 
 enlargement of the regional lymph nodes may be detected; and not 
 infrequently the lymphatics leading to these nodes are palpably 
 enlarged. There follows the second period of incubation, lasting on an 
 average about six weeks; during this period the virus of the disease 
 is spreading past the first group of lymph nodes, and is carried by 
 the blood-stream all over the patient's body. Various prodromal 
 symptoms, such as fever, malaise, headache, vague "rheumatic" 
 pains, etc., may be experienced during this time. As in typhoid fever, 
 the infecting organisms lodge first in the cutaneous capillaries, and 
 the well known rashes of syphilis (secondary lesions, syphiJodermas) 
 are produced; at the same time the lymph nodes all over the body 
 become enlarged, especially the posterior cervical and epitrochlear 
 
 Fig. .38. — Treponema pallidum (SpirochiBta pal- 
 lida) : a, red; b, white-blood corpuscles. 
 
84 CHROXIC IXFECTIOUS SURGICAL DISEASES 
 
 groups. The lesions of this secondary period are not confined entirely 
 to the skin; the mucous membranes usually are also affected, the 
 eruption appearing in modified form in the mouth, the fauces, and the 
 vagina. The histological picture of these secondary lesions presents 
 nothing pathognomonic of syphilis; but the proliferation of the endo- 
 thelial cells lining the bloodvessels is usually sufficient at least to sug- 
 gest the S3"philitic nature of the disease, and the specific organism 
 usually may be detected by smears made from the ulcerated sores. 
 Still later, more or less typical lesions appear in the deeper structures 
 and in the internal organs. These, which are known as gummas, are 
 characteristic of the third stage of syphilis; they consist essentially 
 of an aggregation of round lymphoid cells, with an occasional giant 
 cell at the periphery of the lesion; bloodvessels are less conspicuous 
 in the tertiary than in the secondary lesions of sj'philis. The Tre- 
 ponema pallidum rarely can be found in these tertiary lesions; it is 
 practically never to be detected in those with pyogenic infections. 
 As in the case of tuberculosis, so here, there is a marked tendency for 
 the centre of these lesions to undergo various forms of degeneration, 
 of which the hyaline and fatty are the most usual. Instead of the 
 cheesy pus so characteristic of tuberculous suppuration, the product 
 of syphilitic suppuration is known as gummatous pus. In tertiary 
 as well as in secondary lesions, there is a marked tendency for the 
 disease to be productive at the periphery of the lesions, while degenera- 
 tion occurs in the centre. This is thought to account for the charac- 
 teristic serpiginous form of some of the later skin lesions (Fig. 930). 
 The tertiary lesions of syphilis heal by granulation and cicatrization, 
 with resulting deformity from contraction of the scar-tissue. The 
 scars are typical, both on surfaces and in the interior of organs — in 
 the former situations the regular outline, circular form, and depressed, 
 shiny base of the cicatrix are nearly pathognomonic of a former 
 syphilitic lesion; while the radiating, star-like cicatrices in the internal 
 organs usually may be recognized at a glance. Secondary infection 
 with pyogenic bacteria is a frequent occurrence in gummas; this 
 hastens the destructive process and increases the subsequent deformity. 
 
 No tissues are exempt from the ravages of s^'philis. The favorite 
 seats for the secondary lesions are the skin, mucous membranes, and 
 iris. In tertiary syphilis the periosteum, bones, and joints; deep sub- 
 cutaneous tissues; palate and nasal structures, iris, retina, and choroid; 
 the internal and generative organs; and the nervous system; are those 
 most usually affected. 
 
 This brief sketch of the pathology of syphilis will suflBce for the 
 present chapter. The clinical aspects of the disease, as well as the 
 treatment, will be discussed in Chapter XXVI, while important 
 syphilitic lesions of the various, parts and systems of the body will 
 be described in chapters devoted to regional and systemic surgery. 
 
 Actinomycosis. — The cause of this disease commonly is known as 
 the Ray Fungus, from its appearance under low powers of the micro- 
 scope (Fig. 39); but scientists differ as to whether it shall be classed 
 
ACTINOMYCOSIS 
 
 85 
 
 Fig. 39. — Grains of actinomyces from 
 human pus. X 450. (Marwedel.) 
 
 with the moulds (liyphomycctes) or with bacteria (schizomycetes). 
 This organism is found growing on hay and .straw, and also in the 
 ground, whence it may he incorporated in growing vegctal)lc matter. 
 It was first observed by von Langcnbcck in 1S45, in the pus from a 
 patient with caries of the vertebne. Formerly, instances of tiie dis- 
 ease were considered sarcomatous or carcinomatous in nature. In 
 cattle the ray fungus is a frequent source of disease (lumpy jaw, 
 swelled head) ; but few cases have been obserxed in which actual trans- 
 mission from animal to man has occurred. The usual source of infec- 
 tion in man is believed to be chew- 
 ing of diseased grain; but J. H. 
 Wright (1905) claims that the ray 
 fungus is quite commonly found 
 in healthy mouths, both of man 
 ami beast, and asserts that the 
 action of the cereal is merely to 
 prepare a locus minoris resistentioe 
 where the fungus can develop. 
 
 Pathology. — Like the other in- 
 fectious granulomas, actinomycosis 
 is characterized by a local produc- 
 tive reaction. There is very little 
 tendency to necrosis; but in man- 
 kind secondary infections are the 
 
 rule, and hence suppuration is much more frequent than in the lower 
 animals. The cellular infiltrate surrounding the focus of disease 
 consists of small round cells, giant and epithelioid cells; conversion 
 into granulation tissue occurs, and this tends to cicatrize. The dis- 
 ease is prone to extend along sinuous and branching tracts, suppura- 
 tion occurring in the centre, while the sinuses are lined with the 
 granulomatous tissue. In the pus discharged from these tracts, 
 the colonies of the fungus are visible to the naked eye, as minute 
 yellow granules; these impart to the fingers a gritty sensation due to 
 the presence of calcareous salts. The disease is chronic, and unless 
 vital parts are attacked, life may l)e prolonged for years. Occasion- 
 ally metastatic foci are developed through the blood-stream; but 
 the disease never extends by the lymphatics, and enlargement of the 
 regional lymph nodes usually is an indication of secondary infection 
 (Frazier). 
 
 Symptoms. — Four distinct varieties of human actinomj'cosis are 
 recognized: the oral, the pulmonary, the abdominal, and the cutaneous. 
 The origin of the first has already been described; from the tissues of 
 the mouth proper, the jaws, the cheeks, the neck, and even the skull 
 and brain may be invaded. The pulmonary form, due to inhalation, 
 usually assumes the character of a low grade basal pneumonia; pleural 
 effusion and invasion of the thoracic parietes are frequent. The 
 spine may be involved, and the cold abscesses formed may closely 
 simulate those of tuberculosis. Abdominal actinomycosis, especially 
 
86 
 
 CHRONIC INFECTIOUS SURGICAL DISEASES 
 
 frequent in the neighborliood of the cecum, is of the hyperplastic 
 type, abscess formation and intestinal perforation being rare; the dis- 
 ease tends rather to produce adhesions to the parietal peritoneum, 
 and to invade the a})dominal wall, producing there the characteristic 
 lesions seen whenever the skin is invaded. Cutaneous actinomycosis ' 
 frequently may be diagnosed without microscopical examination of 
 the pus; the sinuses, with the involuted, hypertrophied skin; the 
 chronic and nearly painless course of the disease; the typical "board- 
 like" induration, sharply outlined; and perhaps the presence of hard 
 cords under the skin running from the main lesions out in various 
 directions; all make a picture which is not readily mistaken for 
 an^'thing else. 
 
 Diagnosis. — This must be made from malignant tvmors, which may 
 be closely simulated by the hyperplastic form; from osteon/ i/elitis and 
 
 tubercniovs lesions of bones and joints; from 
 inflamed sebaceous cysts of the face (Fig. 
 40), which, as pointed out by Lexer, some- 
 times bear a striking resemblance to actino- 
 mycosis; and from gummatous and other 
 syphilitic lesions. 
 
 Treatment. — If complete extirpation is 
 possible, this should be done; but in most 
 cases the surgeon must content himself with 
 freely opening all the sinuses, removing the 
 granulation tissue with A'olkmann's sharp 
 spoon (Fig. 451), cauterizing the remaining 
 tracts w ith the actual cautery or some chem- 
 ical caustic (chloride of zinc 10 per cent.), 
 and packing the wounds with iodoform 
 gauze. Iodide of potassium is said to have 
 a remarkable effect, administered in large 
 doses for two or three weeks at a time and 
 then discontinued for one week. Bevan 
 (1908) has used cupric sulphate pills, one 
 quarter of a grain, thrice daily, with marked 
 benefit; he also irrigates the wound with 1 per cent, cupric sulphate 
 solution. This method is based on the agricultural treatment of the 
 diseased grain. Out of door life, and hygienic measures, as for tuber- 
 culosis, are of almost equal importance with topical remedies. 
 
 Madura Foot. — Madura foot, first observed in Madura, India, in 
 1712, is occasionally seen in America. It is due to a fungus closely 
 resembling the actinomyces; one foot only is involved as a rule; 
 very occasionally the hand is affected. A painless swelling forms on 
 the sole; softening and suppuration follow. The course is chronic. 
 Fistulse form, heal, and again break open. Finally all the structures 
 of the foot are invaded. Amputation is the best treatment. 
 
 Blastomycosis. — This is a surgical infection whose chief lesions 
 are manifested on the skin, caused by organisms of undetermined 
 
 Fig. 40. — Multiple seba- 
 ceous cysts of the face simu- 
 lating actinomycosis. Epis- 
 copal Hospital. 
 
ANTIIh'AX 87 
 
 l)i(>l()j;ic'al position, known as l)laston)yc('tos. A few cases of systemic 
 infection have also heen reported. According to He\aii (HKISj "tlie 
 cutaneous lesions have l.een mistaken most often for \ (Trucous tulicr- 
 culosis, less often for syphilis, and occasionally for epithelioma. 
 Tuherculosis is the disease which is most apt to he confused with 
 systemic blastomycosis." The diagnosis is best made by micro- 
 scopical examination of the pus from the cutaneous lesions, or by 
 excluding the existence of tuberculosis by the usual tests. Bevan 
 thinks potassium iodirle is the most valuable remedial measure; he 
 gives as much as OOO grains a day, well diluted. Cupric sulphate has 
 also been used. Hygienic measures are important. In advanced 
 cases the lesions must be treated surgically, by excision, curettement, 
 cauterization, etc. 
 
 Rhinoscleroma.— Uhinoscleroma, a chronic infiltrating, j)roductive 
 infection of the nasal mucous membrane (rarely of the pharynx, 
 larynx, and hard palate), is almost unknown in this country, though 
 common in Austria and southwestern Russia. It is possibly due to a 
 diplobacillus (v. Frisch, 1SS2). It is highly destructive, invading all 
 surrounding tissues, and clinically resembling other infectious granu- 
 lomas. Excision is the best treatment; when this is impossible 
 enough of the growth should be removed to facilitate breathing. 
 
 ACUTE INFECTIOUS SURGICAL DISEASES. 
 
 Anthrax. — This disease, due to infection by the B. anthracis 
 (Davaine, 1873; Koch, 1877), is common in sheep, horses, etc., and 
 may be transmitted to man directly, or through contagion from wool, 
 hides, etc. Invasion occurs through abrasions of the skin or mucous 
 membrane; or through the respiratory or the intestinal tract. The 
 period of incubation is one or two days. The local reaction consists 
 in a cellular and serous exudate, producing marked edema, with a 
 tendency to central necrosis. Eighty-five per cent, of cases affect 
 the head, face, and neck. In severe cases anthrax bacilli enter the 
 blood current, and bacteriemia results; as the bacilli are too large to 
 pass through capillaries of ordinary size, they are arrested at various 
 places and produce car))unculoid lesions in these new situations. 
 
 The cntatieoiis form {Charbon; malignant pustule) is characterized 
 by the formation of a papule, changing into a vesicle, surrounded by 
 an edematous area (Figs. 42 and 43) ; no pus is discharged. The vesicle 
 dries up, a scab forms, central necrosis occurs, the black central core 
 completing the typical picture. The pain ceases, and in mild cases the 
 slough may be cast off, and spontaneous healing occur. In severer 
 cases, lymphadenitis and angeioleucitis develop, toxemia becomes 
 profound, and death may ensue in a few days. The jjulnwnary form 
 {ivoolsorter s disease) is of slight surgical importance; SO per cent, 
 of patients are said to die by the fifth day. The intestinal form is 
 characterized first by symptoms of ptomain poisoning; then by hem- 
 orrhages; and finally the lodgement of the bacilli in the cutaneous 
 
88 
 
 ACUTE IXFECTFOI'S SURGICAL DISEASES 
 
 capillaries produces a widespread carbunculoid eruption soon followed 
 by death. 
 
 Diagnosis. — Anthrax is to be distinguished from other surgical 
 infections by the history of exposure to the infecticni; by the local 
 edematous reaction, with central black core; by the absence of pain 
 
 
 
 
 S<^' 
 
 
 Fig. 4:1. — Anthrax bacilli. Spore formation. From an agar culture twentj--four 
 hours old. About the margin of the photograph are a number of free spores. X 600. 
 (Karg and Schmorl.) 
 
 Fig. 42. — Aiiriiiax ',i face 
 Episcopal Hospital. 
 
 Fig. 4.3. — Anthrax of face. Black slough 
 in centre of edematous area. 
 
 and suppuration; and finally by detecting the bacilli in smears made 
 from the lesion. 
 
 Prognosis. — ^The mortality has \aried from 25 to 33 per cent, in 
 collected cases (Frazier, 1906); but by appropriate treatment it may 
 be reduced to 6 per cent. 
 
GLAXDERS 89 
 
 Treatment. — Excision should be done wlicii possiljlc, iis is usually tlu; 
 case wlii'n an (.'xtrcniity is allcctc<l. Injections of pure carlx^lic acid 
 around tiie lesion (fi\e drf)ps in each puncture) have seemed to be 
 heneficia! in some cases. I'ressure on the pustule is to he avoided. 
 Locally, antiseptic applications are indicated. In severe cases Bar- 
 lacli ( HIOS) surrounds the lesion })y a circle of punctures made hy the 
 actual cautery; he has treated 23 cases with no deaths, ^lost im- 
 portant of all, however, appears to be the use of Selavo's serum (1897); 
 in many cases of the disease (pulmonary and intestinal) it is the 
 only remedy available; 'M) to 40 c.c, in di\idc(l doses, are injected at 
 ditl'erent points in the abdominal wall. This dose may be repeated, if 
 necessary, the following day. In severe cases intravenous injection 
 should be tried (Liiwen, 1908). By these means the mortality has 
 been reduced to G and even to 3 per cent, in large series of cases. 
 
 Glanders ( Farcy j, due to the B. mallei (Loffler and Schiitz, 1882), 
 is common in horses, asses, and mules (equinia); sheep and goats 
 are also afi'ected. P^rom these lower animals 
 the disease is sometimes convened to man by . \ 
 
 the spray emitted by the horse, mule, etc., , / ^!^\>^^ 
 
 in sneezing, or by means of the purulent '^ ^\\<.ll^ 
 
 discharge from other sources. Occupation in \\ tf^^"" ^M 
 stables is therefore a predisposing cause. | *< '^'^i* i*^ J "^ 
 Invasion occurs by inoculation of an abrasion ' v/' *]};» ** 
 
 of the skin (farcy); or of the nasal or buccal \ S\, *' ..^'^ \ 
 mucous membrane {glanders); or through \ {> ' /''j 
 
 the respiratory or digestive tract. The result- 
 ing infection runs an acute (very rarely a gia^,ders^fi37ci?luf mllleif 
 chronic) course. The local lesion somewhat (Abbot.) 
 resembles a tubercle; the regional lymphatics 
 
 are afi'ected early, and dissemination through the blood-stream is 
 rapid. The lesions, wherever situated, are specially characterized by 
 their tendency to rapid suppuration. Along the lymphatics, small 
 harfl nodules (farcy buds) appear, and soon suppurate. In the lungs 
 multiple foci, which soon suppurate, are produced. A diffuse pustular 
 eruption, sometimes mistaken for smallpox, frequently occurs in the 
 skin (Fig. 45j . In the subcutaneous tissues and muscles, hard, movable 
 nodules appear, especially in the biceps, flexors of forearm, rectus 
 abdominis, and pectoral muscles; the nodules soon suppurate. Bones 
 may be invaded, and by implication of joints pyarthrosis may occur. 
 
 Symptoms. — The period of inculcation varies from three to seven 
 days; malaise and indefinite typhoidal symptoms are the first to 
 appear. In glanders, naso-pharyngeal granulomas are the earliest 
 lesions, with ulcerations, causing sero-sanguineous catarrh; then pneu- 
 monic signs; and finally the cutaneous rashes, and subcutaneous and 
 muscular nodes. Leukocytosis usually is not marked. In farcy, 
 the skin affected becomes intensely inflamed; farcy buds appear 
 along the lymphatics and soon suppurate; while the later symptoms 
 resemble the last stages of glanders. 
 
90 ACUTE INFECTIOUS SURGICAL DISEASES 
 
 Diagnosis. — In the acute cases this is rarel}' made l)efore death. 
 The patient's occupation, microscopical examination of the discharges, 
 and a negative Wi(hd reaction, are factors which may indicate the 
 nature of the malady. By the time the characteristic nodes ai)pear, 
 the patient is beyond the reach of treatment. In animals the disease 
 may be detected by the "mallein test" (similar to the tuberculin test, 
 p. 81). The chronic form of the disease resembles the late stages of 
 syphilis. 
 
 Fig. 45. — Pustular eruption in human glander.s. (Dr. Zeit's case.) 
 
 Prognosis. — The disease is extremely fatal (85 to 90 per cent, of 
 cases). Death occurs in from one to three weeks. 
 
 Treatment. — Isolation should be immediate, as the disease is easily 
 convej^ed by both immediate and mediate contagion. If an extremity 
 be affected, amputation is indicated. Localized lesions elsewhere 
 should be excised when possible; at least they should be opened and 
 treated with rigorous antiseptic methods. Curettement and scrub- 
 bing are liable to disseminate the bacilli. Hygienic treatment often 
 is all that is available. 
 
 Tetanus (Lockjaw). — This disease, characterized by tonic and clonic 
 convulsions, and especially by locking of the jaws, is caused by the B. 
 tetani (Fig. 46), discovered by Nicolaier in 1884, and obtained in pure 
 culture by Kitasato in 1889. The bacillus is anaerobic and is found 
 especially in garden soil, barnyards, stables, etc. It probably normally 
 infests the intestinal tract of cattle, and is re-deposited with their 
 dung. So long as the mucosa of their gastro-intestinal tract is intact, 
 they are not liable to infection by this channel. Horses are particu- 
 larly susceptible. Tetanus appears to be endemic in certain localities. 
 
TETANUS 
 
 91 
 
 Fig. 40. 
 
 bacilli, showing spore 
 (Kitasato.) 
 
 Inoculation occurs only tlirou<i;li a wound. (Vyptoficiictic fl'ornicrly 
 called idiopathic) tctaini.s is that t'orni in which the wound of entrance 
 cannot be discovered, lia\iu<j; hcen insi<;iuficant in extent, or l)eing 
 on a nuicous surface. Inoculation is favored by anaerobic conditions 
 of the wound. Thus punctured wounds, contused and lacerated 
 wounds, and wounds in which 
 foreign l)odies (earth, machine 
 oil, splinters, wadding, etc.) are 
 present, offer favorable condi- 
 tions for the development of 
 tetanus. A mixed infection, 
 especially with saprophytic bac- 
 teria, is favorable because these 
 organisms, ])eing aerobic, absorb 
 all available oxygen, and provide 
 anaerobic conditions for the teta- 
 nus bacilli. Tetanus is seen 
 after compound fractures and 
 gunshot wounds; during the 
 puerperal state, when inocula- 
 tion occurs by the genital tract; 
 in the newborn (tetany s nascen- 
 tiiim) from infection of the um- 
 bilical cord; and not infrequently in cases of extensive burns. Con- 
 tagion may spread from one patient to another by the medium of 
 instruments, dressings, etc. Postoperative tetanus has been studied 
 b}' ]\Iatas (1909), who suggests that it is due to germs of tetanus, 
 latent in the patient's intestinal tract, ingested with uncooked food, 
 and infecting the operative wound by fecal contact. There is no 
 good evidence that it is due to the use of infected catgut. 
 
 Pathology. — After inoculation there is an incubation period aver- 
 aging probably about nine days, but which may vary from one day to 
 eight weeks or more; yet when so long a period has elapsed it is not 
 always possible to exclude a more recent inoculation. The duration 
 of incubation is due largely to the distance of the wound from the 
 spinal cord, and to the conditions present at the site of inoculation. 
 Experimentally the bacilli are easily destroyed by the normal tissues 
 of the body; but if these structures (phagocytes and bactericidal 
 fluids) are engaged in combating foreign bodies or other bacteria as 
 well, then the tetanus bacilli begin to exert their influence more 
 promptly. The tetanus bacilli remain in the primary wound; the 
 disease is a pure toxemia; extremely rare are the cases where the 
 bacilli are found in the blood, lymph, or other body tissues. The local 
 reaction caused by the bacilli is in no way characteristic, and is insig- 
 nificant in extent. The toxins they produce are alone responsible for 
 the symptoms of the disease: so long as no toxins are produced, no 
 evil effects are observed from the presence of the bacilli in wounds; 
 and if toxins alone are introduced they produce symptoms identical 
 
92 ACUTE INFECTIOUS SURGICAL DISEASES 
 
 with those seen when tlie bacilli are present and nuiltii)lyinfi; in the 
 wound. The toxins jjroduce no syini)toms until they an; transported 
 to the spinal cord; and they reach the spinal cord only by travelling 
 along the motor nerves. Toxins are absorbed directly' by the nerves 
 of the wounded part and are transported through them to the spinal 
 cord; if the nerve is divided the toxins will ascend as far as the section 
 but not beyond. Toxins also enter the circulation, but cannot reach 
 the central nervous system except when carried to the peripheral 
 ends of motor nerves and absorbed by them. Toxin absorbed from 
 the circulation through short nerves reaches the cord sooner than that 
 absorbed through long nerves. This explains the early appearance 
 of muscle cramp in the face muscles and those of the spine, which 
 may occur before cramps in the wounded extremity. 
 
 In the anterior horns of the cord, congestion, exudation, and ecchy- 
 mosis are frequently observed; but the changes are not pathognomonic 
 for tetanus. When once the cord is invaded, the infection spreads 
 from segment to segment, and the sensory portions are affected 
 directly. The toxin appears to enter into chemical combination 
 with the nerve tissue. Tonic contraction of the muscles is caused by 
 irritation of the motor tracts; while the implication of the sensory 
 portions of the cord renders it so exceedingly susceptible to stimulus, 
 that clonic convulsions are often superadded to the tonic spasms. 
 Our knowledge of the pathology of tetanus is due chiefly to the work 
 of ]\larie and Morax (1902), and of Meyer and Ransom ('190.3). 
 
 Fig. 47. — Opisthotonos in third ria\- of tetanus; death six hours later in convulsions. 
 Note also sardonic grin. Episcopal Hospital. 
 
 Symptoms. — \'ague prodromal symptoms occasionally are noted. 
 When the incubation period lasts less than ten days,. the disease is 
 said to be acute. Sometimes the wound seems painful, or a chill may 
 occur. Usually the first thing noted by the patient is a stiffness of the 
 jaws {trismus) or a painful contraction of the extensors of the neck; 
 occasionally spasm occurs first in the muscles of the wounded part. 
 These primary symptoms are quickly followed, usually in a few hours, 
 by more or less generalized cramps, the extensors almost always over- 
 coming the flexors. Thus the feet are fully extended, the head 
 retracted, and the back arched, so that the entire body may be 
 
TETANUS 
 
 93 
 
 supported on tlie occiput and tlie I'cet {opisthotonos) (Fi^. 47); e////;ro.v- 
 thotoiios is tlie term used for the oi)posite condition, when the action 
 of the flexors })red()nnniitcs, and the l)ody is bowed forward; plriiro- 
 ihotonos, in which lateral de\iation of the s])ine is the chief feature, 
 is extremely rare. These tonic spasms are more or less continuous, 
 full relaxation rarely l)ein<;; attained at any time during the course 
 of the disease. The clonic convulsions are superadded to the tonic 
 spasms, and hrin*:; on aji;ain exaj^gerated deji;rees of opisthotonos, etc. 
 Then the oi)isthotonos relaxes, and until aj;ain excited general rigidity 
 is all that remains; but the jaws usually are persistently shut, the 
 head retracted, and the back arched. The spasms are exceedingly 
 painful, and terribly exhausting. They recur without regularity. 
 They are easily aroused by a draught of air, a slamming door, jarring 
 of the bedstead, etc., as the spinal cord is in a state of extreme hyper- 
 excitability. Difficulty in swallowing 
 is not marked, when once food has 
 entered the mouth. Bronchorrhea is 
 frequently troublesome, and hypostatic 
 or inhalation pneumonia may develop. 
 The muscles of the tongue are not 
 affected and sjx'cch would l)e distinct if 
 the jaws could be opened. Tonic con- 
 traction of the facial muscles produces 
 the so-called sardonic grin. This may 
 persist during convalescence (Fig. 48). 
 Respiration is difficult and labored. 
 Asphyxia is frequently threatened in 
 the tonic convulsions. Spasm of the 
 diaphragm causes the fearful "girdle- 
 pain." The abdominal muscles are 
 "as hard as a board." Retention of 
 urine frequently occurs, and consti- 
 pation is extreme. The recurring con- 
 vulsions deprive the patient of sleep; 
 nourishment can he administered only 
 
 with the greatest difficulty; the mind remains clear to the end, and 
 death is often welcomed by the patient as the only relief. High fever 
 is an unfavorable symptom; at death, and afterwards, the tempera- 
 ture rises rapidly. 
 
 Chronic Tetanus. — This term is used in two senses: (1) For cases 
 with an incubation period of more than ten days. (2) For those in 
 which the patient survives more than fifteen days. In either instance 
 the symptoms are less severe. Occasionally permanent contractures, 
 especially of the jaws, persist after recovery. 
 
 Diagnosis. — This must be based on the suspected wound infection; 
 on the early occurrence of retraction of the head or of trismus; on the 
 generalized tonic and clonic convulsions; on the entire absence of 
 delirium; and on exclusion of all other diseases. It seldom is possible 
 
 Viv,. 4S. - Kisus saidoiiiciis, \h'Y- 
 sisdiif? (luring convalescence fioin 
 tetanus. Ayed seven years; iiicu- 
 hation t(!n days. From a i)atient 
 in the University Hospital under 
 the care of the late Prof. Ash- 
 hurst. 
 
94 ACUTE INFECTIOUS SURGICAL DISEASES 
 
 to recover the bacilli from the point of inoculation, but injection of 
 the patient's blood serum or cerebrospinal fluid into one of the lower 
 animals may cause tetanic convulsions. 
 
 Prognosis. — This is bad. The general mortality is about GO per cent. 
 Anders' figures (1905) showed a mortality of 74 per cent, for cases 
 developing in less than ten days; and of 8.5 per cent, for those which 
 lasted more than fifteen days. Jacobson's statistics (1906), from all 
 the cases treated in various hospitals during given periods, showed a 
 mortality of cS.3.1 per cent, for acute and of 43.6 per cent, in subacute 
 cases. The longer the period of incubation, and the longer life is pre- 
 served after the symptoms develop, the greater is the chance or 
 ultimate recovery. With early diagnosis and prompt and efficient 
 treatment, the mortality of acute cases should be reduced to 20 per 
 cent, or lower (Ashhurst and John, 1913). 
 
 Treatment. — Prevention is better than cure. Extreme care must 
 be exercised in dressing wounds which seem predisposed to the devel- 
 opment of tetanus. Septic punctured wounds should be opened and 
 treated with the most scrupulous antisepsis. Remove all foreign 
 bodies and sloughs. Swab the wound with 3 per cent, alcoholic 
 solution of iodin, rinse with hot peroxide of hydrogen, and pack 
 lightly with gauze soaked in the iodin solution. Lacerated and con- 
 tused wounds must be even more freely drained than where no prob- 
 ability of tetanic infection exists. Inject 1500 units of tetanus anti- 
 toxin into the tissues around the wound, or into any nerves exposed 
 in the wound; and repeat this injection at the end of eight or nine days, 
 since by this time the antitoxin first injected will have disappeared, 
 but toxins may not yet have been produced. 
 
 When the disease has once developed, active treatment is impera- 
 tive. A few hours' delay in recognizing the malady and in instituting 
 proper relief, may render cure impossible. Stiffness of the jaws is 
 enough in a suspicious case to justify the use of heroic measures. 
 The inexperienced surgeon frequently is thrown off his guard because 
 the patient's mind remains so calm and clear. The patient should 
 be isolated at once in a quiet, cool, darkened room, and a special nurse 
 should be placed in charge. The principles of treatment are: (1) To 
 remove the source which supplies the toxins (/. e., the bacilli still in 
 the wound); (2) to neutralize toxins already formed; (3) to depress 
 the functions of the spinal cord; and (4) to sustain the patient by 
 nourishment, nursing, etc. 
 
 1. The first indication involves care of the wound, which is the same 
 as recommended for the prevention of tetanus. 
 
 2. To neutralize the toxins, antitoxin should be used. This is supplied 
 in tubes containing 1500 units (5 c.c.) and 3000 units (10 c.c.) each. 
 It is evident from the pathology of the disease that it is quite extrav- 
 agant to inject it hypodermically or even intravenously. The only 
 way in which it can act upon the toxins ascending from the wound is 
 when it is injected directly into the motor nerves of the part affected, 
 as first emplo\ed in 1902 by Kiister in a case of laboratory infection. 
 
TETANUS 95 
 
 When tji\t'ii li\ jHukTinically it is al).S()rl)C(l by the lymph spaces, 
 readies tlie veins, i)asses throujjh the heart and lunfi;s, and is then 
 (listril)ute(l l)y the arteries to the entire Ixxly, (»nl\' a lioniceojjathic 
 (h)se reaching the special ner\'e or ner\es along which the toxins are 
 travelling to the spinal cord. If used suhcutaneously at least 100, 00(3 
 units should he administered in the first twenty-four hours. It has 
 been j)ointed out by Ashhurst and John (191.')) that antitoxin injected 
 into the subarachnoid space of the cord i)r()bably acts directly on 
 the nerve roots, and such immediate and fa^'orable effects from the 
 repeated intraspinal administration of antitoxin have been reported, 
 that I think it should be employed in every case. Anesthesia is not 
 necessary, though often desiral)le. Chloroform is better than ether. 
 The hollow needle is inserted between the second and third lumbar 
 spines (p. 157), and a few cubic centimeters of the subarachnoid fluid 
 are drawn off; the antitoxin syringe is then attached to the needle, 
 and from oOOO to 10,000 units are slowly injected. If the site of 
 inoculation is on the upper extremity or head, the foot of the table 
 maj' be raised, to allow the antitoxin to gravitate toward the medulla. 
 This injection may be repeated every day or two, as required; it is 
 easier than intraneural infiltration, which requires anatomical as well 
 as surgical knowleflge. If no marked improvement follows the sub- 
 arachnoid injection, within six or eight hours, the main nerve or 
 nerves leading from the site of infection should be isolated under 
 chloroform anesthesia, and as much antitoxin as possible should be 
 injected into each nerve, by various punctures into its substance. 
 The nerve swells up so quickly that no large amount can be intro- 
 duced; on several occasions I have injected 1500 units (5 c.c.) into 
 the sciatic nerve all at one dose. It is not true that the pressure, 
 rather than the antitoxic action, blocks further absorption of the 
 toxins, since intraneural injections of saline solution are without effect. 
 Antitoxin seems perfectly harmless, and no fear need be entertained 
 of using too much. The incision should not be closed, but a stout 
 silk or linen ligature, looped loosely around the nerve, should be left 
 hanging from the wound, which should be lightly but copiously 
 dressed. If the symptoms persist, the patient must be chloroformed 
 again the next day, and the intraneural injections repeated. Possible 
 injury to the nerves, which does not appear to have been reported, 
 is of insignificant consideration, compared to the preservation of life. 
 The nerves to be so treated in the lower extremity should be exposed 
 in the upper thigh; for wounds of the sole of the foot, the sciatic nerve, 
 and for injuries of other parts of the lower extremity, the anterior 
 crural and obturator as well as the sciatic must be injected. In the 
 upper extremity the nerves may all be exposed by a single incision in 
 the axilla; or the brachial plexus above the clavicle may be injected. 
 For wounds of the trunk, intraspinal injection is the best available 
 remedy; this is also the case in wounds of the face and head. Intra- 
 cerebral injections, after trephining the skull, have been used, but 
 as the cerebrum is not materially affected by the toxins this operation 
 
96 ACUTE INFECTIOUS SURGICAL DISEASES 
 
 probably is useless. Rogers (1905) has used intramedullary injections 
 with success, in desperate cases: he introduced the needle in the 
 cervical, upper dorsal, or lumbar region, and poked around until 
 jerking of the limbs indicated that he was scratching the cord 
 itself. 
 
 3. To depress the functions of the spinal cord drugs may be given 
 by mouth if the patient can swallow, or by the rectum; hypodermic 
 administration is best when possible. These drugs should be admin- 
 istered in doses sufficient to produce some effect; 10 to 20 grains 
 of chloral hydrate, and twice as much bromide of potassium, may 
 be given as often as every three hours; more should be given if the 
 patient requires it, and less if it proves to be sufficient to relieve 
 the pain and diminish the rigidit3\ ^lorphin is of very little value. 
 Chloretone has given gratifying results (Hutchings, 1909). It is 
 administered by mouth or rectum in doses of from 30 to 60 grains, 
 dissolved in whisky or hot olive oil. 
 
 Treatment by intraspinal injections of magnesium sulphate, intro- 
 duced by Blake of New York in 1906, is based on the anesthetic effect 
 of this drug, when injected into the subarachnoid space (Meltzer, 
 1905). It acts as a spinal depressant, and should not be used as a sub- 
 stitute for antitoxin. Solutions of 12.5 to 25 per cent, strength are 
 employed, and 1 or 2 drachms (5 to 10 c.c.) are used at each 
 injection (1 c.c. for every 25 pounds of body weight). It is a dangerous 
 remedy, and several deaths have been reported following its employ- 
 ment. 
 
 Carbolic acid injections, introduced by Bacelli (18SS), are supposed 
 by some to have a specific action in tetanus. Subcutaneous injec- 
 tions of Y P^r cent, watery solution are administered, every one 
 or two hours, preferably along the spine, until 80 or 100 eg. are 
 given in twenty -four hours, watching for constitutional symptoms 
 of carbolic acid poisoning. Experimental evidence (Camus, 1912) 
 shows this treatment to be useless, but clinically some good results 
 are reported. 
 
 4. The nursing of the patient is very important. Clear the bowels by 
 a brisk purge early in the disease; watch for retention of urine; guard 
 against bed-sores. Enforce feeding, by the stomach tube passed under 
 a general anesthetic if necessary. 
 
 Hydrophobia (Rabies, Lyssa). — ^This disease, whose exact cause 
 is unknown, is characterized by clonic spasms, especially of the faucial 
 and respiratory muscles; it results from inoculation with the virus 
 contained in the saliva of rabid animals, notably dogs, wolves, cats 
 (also in foxes, sheep, goats, pigs, skunks, deer, etc.). Any mammalian 
 may be affected. It is disputed that it is ever conveyed from man to 
 man. Though infection occurs in the vast majority of cases by bites, 
 it may also occur through scratches by claws infected with saliva, or 
 by an animal licking an existing wound. Wolf bites are most dan- 
 gerous, because it is said the hands and face, unprotected by clothing, 
 are usually bitten; and because the sharper teeth more readily pene- 
 
UYDUOl'llOBlA 97 
 
 tnite protoctod parts. It is possible that tlu; \iriis may ))e partly 
 wiped oil" the teeth of animals hy i)assiii<^ tliroii<;h clothiiij^. 
 
 The disease is found in do<;s in two forms, the J'lirioiis and the 
 paralytic. In the former, the dof^ is at first sullen, retiring to his 
 kennel, antl looking askance at every one; after several hours he 
 becomes exceedingly fidgety, continually shifting his posture; suddenly 
 he becomes irritable, with a snai)i)ing bark, an unsteady and staggering 
 gait; the tongue lolls from his mouth, swollen and red; the saliva is 
 profuse and viscid; there is loss of appetite and presence of thirst. 
 Later, paralysis of the extremities occurs, breathing and deglutition 
 become spasmodic, and convulsions bring on death. In the j)aralytic 
 form, the disease passes at once from the sullen to the i)aralytic stage; 
 the dog is shy and melancholic; there is no disposition to bite; he is 
 haggard and suspicious; has no fear of water, l)ut docs not drink; the 
 tongue lolls, the salixa dribl)les, breathing is difficult and laborious; 
 and tremors, vomiting, and convulsions precede death (Youatt; 
 quoted by Forbes, 1888). 
 
 Pathology. — The virus, entering the wound with the saliva, and 
 probably deri^-ed from the salivary glands, is absorbed by the nerves 
 of the bitten part (Di Vestea and Zagari, 1887), and travels by them 
 to the spinal cord; whether some toxin alone, or the infective agent 
 itself is thus transmitted, is still unknown. Some of the virus may 
 travel through the neural lymphatics. The virus, after reaching the 
 cord, travels up it to the medulla, cerebellum, and cerebrum; it also 
 travels out along the spinal and cranial nerves, and in this way reaches 
 the salivary glands of the patient, especially the submaxillary and 
 sublingual; the saliva becomes highly infectious. After death there 
 are found in the cerebrum, cerebellum, medulla, and cord, and also 
 in the salivary glands, various degenerati\'e changes, especially marked 
 in that part of the cord which receives the nerves of the bitten part. 
 The most important microscopic changes are in certain of the per- 
 ipheral ganglia and in the hippocampal convolution. Van Gehuchten 
 and Nelis in 1900 found changes, seen best in the ganglia of the vagus 
 and sympathetic nerves, consisting in proliferation of the endothelial 
 cells lining the capsule of the ganglion, and filling up the spaces between 
 the capsule and the proper cells of the ganglion. Negri (1903) found 
 in the pyramidal cells of the cornn Ammonis, and in Purkinje's cells 
 in the cerebellum, certain cell inclusions which he regarded as para- 
 sites and the cause of the disease. Nearly all observers admit that 
 these ganglionar changes and the presence of Negri bodies are pathog- 
 nomonic of rabies; they are found in other diseases only with the 
 greatest rarity; but many dispute Negri's claim that the bodies 
 described by him are parasites, and deny that they are the cause of 
 the disease. liambaud (1907) points out that their distribution is 
 not what would be expected of the specific cause of rabies; that the 
 virus passes through filters which arrest the Negri bodies (Park 
 thinks this not a valid objection) ; and that protozoa survive tempera- 
 tures (45° C.) which readily render the rabic virus inert. 
 7 
 
98 ACUTE INFECTIOUS SURGICAL DISEASES 
 
 Symptoms. — After inoculation, there is a period of incubation, 
 varying from four or five days up to several months or a year. The 
 average period in man is forty days (Ravenel, 1901). Incubation is 
 shortest following bites of the face and other exposed parts, also fol- 
 lowing wolf bites. The original wound usually has firmly healed long' 
 before any symptoms arise. The course of the disease was described 
 by Virchow as embracing three stages: (1) The first stage, which may 
 be absent, but which usually lasts from a few to twenty-four hours. 
 There is malaise, lassitude, headache, twitching of the throat, stiff- 
 ness of the neck, a feeling of suffocation, and rarely slight delirium. 
 There is seldom any abnormal sensation in the wound. During this 
 stage the virus probably is ascending the cord. (2) The second 
 stage is evidenced by increasing stiffness and pain in the tongue, 
 throat, and jaw muscles; there is dysphagia, dryness, and great 
 thirst; profuse salivation, the saliva being exceedingly tenacious and 
 viscid; this necessitates repeated hmcking which has been fancifully 
 likened to the bark of a dog. Violent spitting is exceedingly charac- 
 teristic. The patient is fearful of infecting those about him. Speech 
 is difficult, being often choked off by gasps and sobs due to pharyngeal 
 and laryngeal spasm. Swallowing becomes impossil^le, the sight of 
 food or liquids, and sometimes the very sound of running water, 
 bringing on renewed paroxysms. The special senses become pre- 
 ternaturally acute; according to Rambaud, the slightest draught 
 of air, as breathing gently on the patient, always produces faucial 
 spasm. General convulsions ensue; there is high temperature, rapid 
 pulse, and polynuclear leukocytosis. The urine is deficient; it may 
 contain albumin or sugar. The mind seems in terrific dread, in 
 unutterable despair, or furious anger. Insane impulses and delusions 
 are not uncommon; the staring eye, tensely drawn mouth, with 
 bloody foam on the lips, and haggard countenance precede mania, 
 which closes the second stage. The entire duration of this frightful 
 scene may be twenty-four to forty-eight hours; and death from 
 asphyxia in a convulsion is frequent. (3) The third, or paralytic stage 
 is evidenced by exhaustion succeeding to mania and convulsions: 
 saliva dribbles from the hanging mouth, the tongue lolls, and a horrible 
 gurgling in the throat portends dissolution (Forbes, 1881). The entire 
 course of the disease may be run in sixteen hours, or it may last four 
 or five days; seldom longer. In rare cases the furious stage is entirely 
 absent, the disease resembling the paralytic type seen in dogs. 
 
 Diagnosis. — This affection, which is exceedingly rare, is distin- 
 guished from pseudo-rabies (hysteria), by the history of a bite from 
 a truly rabid animal;^ by the period of incubation, which is never less 
 
 ^ To determine whether or not the animal is rabid, it should not be killed 
 immediately, but should be kept under observation for several days, or at least 
 until the clinical signs are noted by a competent veterinarian. If such is not avail- 
 able, the dog's head should be cut off with an aseptic knife, and sent to a competent 
 veterinarian or pathologist, who will determine from the microscopical appear- 
 ances of the plexiform ganglion and cerebrum, whether or not the animal was 
 afflicted with rabies. This fact may also be determined by inoculations into other 
 animals, but this method may take several weeks. 
 
IlYDIiOrUOBIA 99 
 
 than four days; and by the ahnost invarial)ly fatal termination within 
 ten (lays. In liysteria the symptoms are often immediate, the harking 
 and hydrophobia are absurdly exaggerated, the dog is not mad, and 
 death does not occur. Tetanus is due to a wound, not a bite; there 
 is no excitement, fury or mania; the convulsions are tonic more than 
 clonic; the jaws are firmly shut and cannot be opened; there is no 
 spasm of the tongue and fauces. Tetanus is a quiet disease; apart 
 from gritting of the teeth during convulsions, the patient makes no 
 noise. Ivabies is a furious and noisy disease. 
 
 Prognosis. — It is now said that from 10 to 15 per cent, of those bitten 
 by rabid animals are liable to develop the disease; it was formerly 
 claimed by Pasteur and his followers that the incidence was much 
 higher, even as much as 75 per cent. Not only is it an unusual disease 
 in man, but it is by no means common in dogs and other animals. 
 It is most frequent in France, Germany, and Russia; it is very infre- 
 quent in Great Britain where there are extremely stringent quaran- 
 tine laws against the inij)ortation of dogs; and almost unknown in 
 Norway and Australia. Most surgeons never see a single case. I 
 never saw one. Our entire knowledge of the disease is due largely to 
 veterinarians and to directors of Pasteur Institutes. The disease 
 when it really does occur is frightfully fatal. There are a very few 
 well authenticated cases of recovery, accepted as such by competent 
 critics. 
 
 Treatment. — This must be both preventive and curative. The former 
 includes police regulation of dogs and other domestic animals, as well as 
 ordinary surgical treatment for a poisoned wound, and, if the patient 
 wishes, the so-called Pasteur treatment by preventive inoculation. As 
 soon as the wound is received, constriction should be applied on its proxi- 
 mal side, to prevent possible absorption ; and a cupping glass should be 
 applied to suck out as much of the virus as possible. In emergency, 
 the patient should suck the wound with his own mouth, spitting out 
 the blood thus extracted. The best antiseptic, according to Rambaud, 
 is corrosive sublimate (1 to 1000); the compound tincture of iodin is 
 also good; lemon juice, which is an excellent antidote experimentally, 
 may be used in emergency. Caustics are worthless, unless heat is 
 used ; and when available antiseptics are better than heat. 
 
 The Pasteur treatment is based on the theory that, even during the 
 period of incubation, inoculation with extremely attenuated virus, 
 whose strength is gradually increased, will be sufficient to immunize 
 the patient against the disease. The attenuated virus is obtained 
 from the spinal cords of rabbits dead of hydrophobia; the quantity 
 (not the quality) of the virus in the cords gradually diminishes in 
 dry air. The first inoculation is made with an emulsion of a cord 
 from a rabbit dead twelve to fourteen days, and the course of treat- 
 ment extends over about two weeks. There is no doubt that in the 
 vast majority of cases inoculation of healthy animals according to 
 this system will immunize them against rabies; but to conclude from 
 this, that inoculation of patients already infected will also be eflficient, 
 
100 ACUTE INFECTIOUS SURGICAL DISEASES 
 
 is not logical. From practical experience, however, it may be said 
 that there is no good reason to doubt that inoculation according to 
 Pasteur's method, under the latter circumstances, has rendered most 
 of the patients so treated immune. But it must not be forgotten that 
 the vast majority of patients treated in Pasteur Institutes never 
 would have developed rabies under any circumstances; many of 
 them are bitten by animals that are not rabid; and therefore their 
 inoculation in most instances is perfectly useless. Moreover, there 
 is not a shadow of doubt that in a few well authenticated cases no 
 immunity has been procured by the inoculations, the patients sub- 
 sequently developing and dying from the disease; and it has even 
 been open to suspicion that these very patients might have been 
 among that large number who, even without the inoculations, never 
 would have developed the disease — in other words, that the danger 
 of contracting rabies as the result of the inoculations, though very 
 remote, is not altogether imaginary. The actual mortality attending 
 the Pasteur treatment is given as less than 1 per cent, ; but as from 
 these statistics it is customary to exclude all those patients who 
 develop rabies within fifteen days after the last inoculation (Rambaud), 
 the number of those in whom immunity is actually produced is con- 
 siderably less than would appear if this fact were not taken into con- 
 sideration. Before a surgeon recommends the preventive treatment 
 by inoculation he should, I think, place all these facts plainly before 
 the patient; and if the patient wishes to take this very remote risk, 
 and the surgeon is convinced that he was infected by a rabid animal, 
 no time should be lost in having this treatment instituted. 
 
 The curative treatment is nearly hopeless. Hyoscin and curare, 
 hypodermically, are the best drugs; chloral and morphin have little 
 effect. Proctoclysis of saline solution, with large doses of bromides 
 by the rectum, may be tried. Amyl nitrite or chloroform may be used 
 for the convulsions. The saliva should be sterilized. 
 
CHAPTER IV. 
 TUMORS. 
 
 In studying tlic iiiHanimatory ])rocess it was seen that the local 
 reaction induced was usually sufficient to overcome and destroy the 
 origin of the trouble; in the case of the infectious granulomas, instead 
 of an efficient reaction, the indications of inflanunation were found to 
 be very slight, and cellular proliferation was the main characteristic 
 of the process. Yet in both these instances the cell proliferation was 
 incontestably in the nature of a reaction to external stimulus. In 
 tumors we find a pathological process characterized by purposeless, 
 more or less unlimited, cellular proliferation of unknown cause, pro- 
 ducing practically no reaction in surrounding tissues. The cells of 
 tumors seem to be a law unto themselves: they do not follow the 
 ordinary processes which subserve the purposes of the organism as 
 a whole; their only function appears to be proliferation, and this 
 they evince without discoverable purpose or known cause. 
 
 For an understanding of tumor processes a knowledge of embry- 
 ology is necessary, because the most logical classification of tumors 
 which has yet been proposed (Adami, 1902)^ is that based on their 
 histogenetic characteristics, and because the ultimate cause of tumor 
 formation seems to lie in inherent characteristics of the cells them- 
 selves, not in stimulus from without nor in relief from constraint by 
 surrounding structures. 
 
 Definition. — This is difficult, because the cause of tumors is not 
 known; a definition therefore has to be formed solely from the objective 
 characteristics of fully formed tumors. Adami accepts as satisfactory 
 the statement of C. P. White that "a tumor is a 7nass of cells, tissues, 
 or organs resembling those normally 'present, but arranged atypically. 
 It grows at the expense of the organism icithout at the same time sub- 
 serving any nsefnl function." 
 
 GENERAL CHARACTERISTICS OF TUMORS. 
 
 The word tumor means a swelling, and all tumors are character- 
 ized by a more or less localized swelling, which usually is both visible 
 and palpable. Tumors may be multiple or single, may occur at any 
 age, and in any situation. 
 
 Form. — A tumor growing on the surface of the body assumes a 
 typically rounded form (Fig. 49) ; one in the internal organs, or beneath 
 
 1 In the following paragraphs the teaching of Adami, and sometimes his words, 
 have been closely followed. 
 
102 
 
 TUMORS 
 
 a resistant fascia, or compressed by other parts of the body will spread 
 ill the direction of least resistance; tumors may thus become irregular 
 
 in form (nodular, ])aj)illary, etc.). 
 Consistency ^'aries greatly, being 
 dc})enden t upt m the ty i)e of tumor : 
 fatty tumors are soft, bony and 
 cartilaginous, are hard fibromas 
 and are more or less firm. Rate of 
 Growth: This is usually slow, the 
 increase in size being measured 
 by months or years rather than 
 by weeks or days; in general, the 
 more rapid the growth, the worse 
 the prognosis. Slowly growing 
 tumors seem to pro^'oke a feeble 
 reaction in the surrounding tis- 
 sues, so that they become sur- 
 rounded by a more or less well 
 defined capsule; those of rapid 
 growth extend into normal tissues 
 in various directions before a cap- 
 sule can l)e formed. Manner of 
 Growth: Growth occurs simul- 
 
 FiG. 49. — Lipoma of right arm. , i • ii , e ^ 
 
 taneously in all parts or a tumor, 
 not only at the periphery or in the centre, though in certain tumors 
 growth at one place is much more marked than at others. The more 
 rapid the growth, the more 
 apt are the central cells to be 
 squeezed out of existence, and 
 therefore in such tumors cen- 
 tral degeneration is common, 
 leading at times to cyst for- 
 mation. Size varies so greatly 
 that no clear statement can 
 be made (Figs. 50 and 51). 
 
 Malignancy. — From the 
 above it is evident that cer- 
 tain tumors are less benign 
 than others. Even tumors 
 recognized as clearly benign 
 may be dangerous from their 
 size or position. The size of 
 a tumor may impair the 
 patient's health by requiring 
 an extraordinary amount of 
 nourishment; its position, 
 even if small, may threaten ^i«- so.-Papiiioma of face. 
 
 life, as in growths of the larynx threatening suffocation, in the ali- 
 mentary canal causing obstruction, or in the brain causing pressure 
 
TIIEORJES OF rUMOR FORMATIOS 
 
 103 
 
 oil vital centres. But tumors conii);ir;iti\ely sniiill in si/.c iind innocu- 
 ous in position may by their inherent ciiaracteristics be exceedingly 
 dangerous to life. These characteristics are (Adami): Embryonic 
 character of the tumor cells, leading to rapid growth; this in turn gives 
 the surrounding tissues no opportunity to encapsulate the growth, 
 with the result that itifiltration of the surrounding tissues occurs, this 
 infiltration extending far beyond the limits visible to the naked eye 
 or discoverable by palpation. Metastasis: Some of the tumor cells by 
 their rapid growth may break into bloodvessels and be carried by the 
 blood to the nearest set of capillaries, and may even pass through 
 these (pulmonic, hepatic) and enter 
 the next set, in either situation 
 lodging and, unless killed by the 
 tissues of the part in which they are 
 arrested, giving rise there to new 
 growths {metastases) similar to the 
 original tumor. (It is held by 
 Orth and certain other pathologists 
 that normal cells surrounding evi- 
 dently malignant cells may become 
 infected by the latter, and them- 
 selves aid in the formation of the 
 tumors. I think it is more reason- 
 able to consider, with Ribbert, 
 Adami, and others, that metastases 
 are due to the proliferation solely 
 of cells which have been trans- 
 ported from the primary tumor.) 
 The tendency to central degenera- 
 tion and cyst formation has already 
 been alluded to; in addition, super- 
 ficial parts, those furthest removed 
 from the blood-supply, whether on 
 mucous or cutaneous surfaces, tend 
 to sloughing and ulceration. These 
 malignant tumors, moreover, tend 
 
 to return after removal (recurrence) , either because this was incom- 
 plete in the first place, or because other previously normal cells become 
 anarchistic in their turn. Further, malignant tumors produce cachexia; 
 this is not in any sense a specific cachexia, but is caused by the drain 
 on the natural resources of the body by the tumor, by anemia due to 
 hemorrhages from its ulcerated surface, by toxemia through absorp- 
 tion, or by intoxication from perverted metabolism. 
 
 Fig. 51. — Excision of right clavicle for 
 alveolar sarcoma, March 3, 1894, at age 
 of nineteen years. Recurrent growth re- 
 moved April 20, 1895. Present recurrence 
 noticed September 1896. Grew very rap- 
 idly after April, 1897. From a patient in 
 the University Hospital under the care of 
 the late Prof. John Ashhurst. 
 
 THEORIES OF TUMOR FORMATION. 
 
 Most of the theories in favor at the present day account only for 
 one or two types of tumor. Cohnheiins theory is to the effect that 
 
104 TUMORS 
 
 during fetal life certain groups of cells become displaced from their 
 normal site, remain undeveloped and latent (cell "rests") until some 
 future period of adult life, and then from some unknown cause begin 
 to proliferate and form a tumor; this theory accounts very well for 
 tumors of distinctly fetal origin (teratomas), but there are many 
 other tumors which under no circumstances can be considered due 
 to cell rests. Ribbert's theory, a modification of Cohnheim's, sup- 
 poses that, besides fetal displacement, also post-natal displacement 
 of nests of cells may occur; but that proliferation of such displaced 
 cells is not due to stimulation from without nor to any inherent 
 qualities of the cells themselves, but to lack of restraint by the sur- 
 roimding tissues. Yet, in the process of regeneration (p. 30) cells 
 exhibit such qualities in marked degree, yet no tumor results except 
 in most exceptional instances. Parasitic Theory: This is based 
 chiefly on observations which tend to show the infectiousness of cer- 
 tain malignant tumors; such tumors (carcinoma and sarcoma) may 
 be transplanted from animal to animal, their virulence, if it may be 
 so called, being markedly increased by passing them through series 
 of susceptible animals; and in many such tumors parasites of various 
 kinds have been found. But the parasites are of various kinds, their 
 etiological value has not been proved, and even if it were, this theory 
 would explain the growth of only one class of tumors — the malignant. 
 This reduces us, therefore, to the theory that the origin of tumors lies 
 in perverted habits of the cells themselves, however it may be aided 
 by the abnormal position of the cells (Cohnheim), by their release 
 from restraint (Ribbert), or by their stimulation by parasitic forms of 
 life. The utmost that we definitely know of tumor cells is, as Adami 
 puts it, that they have gained the habit of growth, and have lost that of 
 function. 
 
 CLASSIFICATION OF TUMORS. 
 
 Functional development of cells necessitates their specialization. 
 The most undeveloped cells are said to be toti-potential (capal)le of 
 everything) ; more developed cells are pluri-jMential (capable of more 
 than one thing) ; while cells which are most developed are uni-jjotential 
 (capable of only one thing) (Barfurth). Basing his ideas of the 
 nature of tumors on the inherent properties of the cells themselves, 
 Adami recognizes three main groups of tumors, according to whether 
 the tumor arises (1) from absolutely undifferentiated (toti-potential) 
 embryonal cells, (2) from partially differentiated (pluri-potential) 
 embryonal cells, or (3) from uni-potential cells, that is, cells which 
 can form only one type of tissue. The first class (Teratoma) is deri^'ed 
 from cells which might possibly, at a later period, be developed into 
 any form of tissue or any organ, or even into a complete individual. 
 The third class (Blastoma) is derived from cells which (before the 
 tumor originates) ha\e so far developed that they can give rise to 
 only one form of tissue, e. g., connective tissue cells can produce only 
 connective tissue tumors, epithelial cells can produce only epithelial 
 
CLASSIFICATION OF TUMORS 
 
 105 
 
 tumors, etc. Tlio second or iiitcrnu'diarN- ty])C of tumor (Terato- 
 blastomaj is (lcri\ cd i'rom cells only so far dilferentiated that tliey can 
 produce more than one form of tissue, l)ut not all forms (Fig. ")2). 
 Tumors composed only of one tissue are rare. 
 
 Fig. 52.— Diagrammatic representation of section through vertebrate Ijody to show 
 ontogenetic relationship of the various orders of tissues. A. Of Icpidio type: 1, epiderm 
 and its glands (cpiblastic) ; 2, mucous membrane of digestive canal and its glands, liver, 
 etc. (hypoblastic) ; 3, endothelium lining serous cavities (mesoblastic) and glands, like 
 renal cortex, of mesothelial origin; 4, vascular endothelium of late mesoblastic origin. 
 B. Of hylic type: 5, spinal cord, brain, and nerves (epiblastic) ; 6, notochord (hypo- 
 blastic) ; 7, connective tissues of the body (mesenchymatous) ; 8, myotomes, striated 
 muscle of body (mesothelial). C. Cavities: 9, lumen of digestive tube; 10, body cavity. 
 (Adami and McCrae.) 
 
 Teratomas. — These are divided by Adami into two main classes, 
 according to whether the teratoma is derived from the same indi- 
 vidual as the person possessing the tumor, or Avhether it is derived 
 from a twin which, becoming atrophic in embryonal or early fetal life, 
 remains only as a fetal inclvsion. This latter class produces the 
 various forms of monsters, chiefly of interest to obstetricians. The 
 former class comprises those tumors usually known by the name 
 teratoma. These tumors may spring from germinal cells, or from non- 
 
106 
 
 TUMORS 
 
 germinal cells; in the former instance the tumor is foimd in the ovary 
 (ovarian "dermoid"), where a large cyst is usually formed, or in the 
 testicle, where the growth (rare) is chiefly solid, with only a small 
 cyst; while in the latter instance the most frequent site is at one end 
 of' the cerebrosi)inal axis (epignathus, sacral teratoma). As such 
 tumors spring from toti-potential cells, they may include all varieties 
 of tissues. If the tumor contains elements formed from all three of 
 the germinal layers it is known as an embryoma. Epithelial struc- 
 tures are most frequently found, especially hair and teeth (epiblast), 
 or glandular tissue (epi- or hypoblast) ; occasionally cartilage or bone 
 (mesoblast). 
 
 These tumors usually are present at birth (Fig. 53), but frequently 
 are not noticed until puberty. Their size, shape, and consistency 
 
 vary according to their location 
 
 n'^^'llipil^^^lH and the structures composing them. 
 ^^^^1 They usually grow rapidly when 
 ^^^1 growth once begins, and may become 
 jWH malignant, giving rise to metastases. 
 ^iiP'''*4^ ^ jtfl They are best treated by excision; but 
 n^^^ -c!>w>." *!^B i^i the newborn operation should be 
 postponed until it is apparent that the 
 child's constitution is otherwise suf- 
 ficient to support life. 
 
 Terato-blastomas.^ — These tumors, 
 derived from pluri-potential cells, 
 comprise most of the so-called 
 "mixed tumors" — tumors in which 
 tissues are found which do not nor- 
 mally exist in the organ or tissue 
 affected. In the parotid, and sometimes in the submaxillary gland, 
 cartilaginous tumors are not unusual; in the kidney such tumors 
 rarely have more than one variety of aberrant tissue, and have 
 received various names according to the predominant tissue — rhab- 
 domyoma, adenosarcoma, etc. The tumor known as chorio-epithelioma 
 (deciduoma) maligmnn belongs to this group; it is formed by neoplastic 
 development of cells of the chorionic villi. The placerital mole is 
 believed to be the early stage of such development; when the cells 
 invade the uterine sinuses malignancy is evident and the deciduoma 
 is present. 
 
 The terato-blastomas, as well as the pure embryomas, often exhibit 
 malignant characteristics, and are best treated by excision. 
 
 Blastemas. — ^These tumors, forming by far the largest group of 
 neoplasms, result from the independent growth of uni-potential cells. 
 They are divided by Adami into two main groups, according as they 
 are composed chiefly of cells arranged like epithelial, or rind, tissues 
 (Lepidic tumors, Lepidomas), or of cells arranged like the stroma or 
 pulp of tissues and organs {Hylic Tumors, Hylomas). The charac- 
 teristic of all epithelial structures (skin, mucous mem])rane, endo- 
 
 FiG. 53. — • Sacro-coccygeal tera- 
 toma. Italian girl, aged six months. 
 Pennsylvania Hospital. 
 
LIPOMA 
 
 Wi 
 
 tlu'liuin) is that tlu' cells jirc ])l;i(r(l closely toj^ctluT, there heiiiij; ;in 
 ahseiice ot" deliiiite stroma hetween the indixidiiai cells, and no blood- 
 vessels penetrating hetween the \arioiis <;Ton|)s of cells. The ciiar- 
 acteristic of all i)nli) tissnes (nerxons tissm\ nniscle, hone, etc.) is that 
 the specific cells lie in and are sei)arate(l hy a definite stroma, in 
 which hlood and lym|)h \(>ssels may or may not he present. Lepidic 
 and hylic tnmors may be either typical or atypical. The typical blas- 
 temas are slow growing, and their structure approaches that of normal 
 adult tissue; the atypical l)lastomas are composed of rather immature 
 cells, do not closely resemble adult tissue, and grow raj)i(lly. Typical 
 blastomas are more or less encapsulated; the atypical are infiltrating. 
 Typical blastomas are benign, atypical blastomas are malignant. 
 
 E.xamples of typical (benign) lepidic tumors are papilloma, adenoma; 
 of hylic tumors, are fibroma, osteoma. Examples of atyj)ical (malig- 
 nant) lepidic tumors are epitlwlioma, carcinoma; of atypical hylic 
 tumors are the numerous varieties of sarcoma. 
 
 In addition to distinct tumors, certain blastomatoid f/rouihs (Adami) 
 must also be recognized; they approach more closely the reacti^■e 
 changes of infianunation, and correspond to 
 the "continuous hypertrophies" or "out- 
 growths" of Paget (1853) as distinguished 
 from the true tumor or "discontinuous 
 hypertroj)hy" of that author. 
 
 Typical (Benign) Hylic Tumors. — The most 
 important of these are tumors resembling 
 the following normal tissues: Fat (Lipoma); 
 Fibrous Tissue (Fibroma); Cartilage (Chon- 
 droma); and Bone (Osteoma). Although 
 many varieties of tissue may exist in the 
 same tumor, yet one usually is so predomi- 
 nant as to give its name to the growth. If 
 another tissue is present in fairly large 
 amount, a compound term is used, thus fibro- 
 lipoma, the tissue present in greatest abun- 
 dance always being named last. 
 
 Lipoma. — This may consist rather in an 
 hypertrophy of fat normally present (lipo- 
 matosis, a "continuous hypertrophy or out- 
 growth") than in an actual tumor. Multiple 
 lipomas are not rare (Fig. 54). A lipoma 
 rarely is well encapsulated. It grows slowly, 
 produces no discomfort except from its size 
 or position, and is absolutely benign. The 
 skin over it is not discolored nor adherent, 
 though a slight dimpling may be present oc- 
 casionally, from fibrous bands supporting the 
 
 tumor between the skin and deep fascia. It is soft, easily movable 
 on the underlying tissues, and semi-fluctuating. A lipoma sometimes 
 
 Fig. 54. — Lipomatosis 
 aiTecting only the extremi- 
 ties, aged fifty-one years. 
 Began at fourteen years. 
 Father had the same con- 
 dition. Episcopal Hospital. 
 
108 
 
 TUMORS 
 
 will gradually shift its position under the force of gravity. It may occur 
 oil any part of the body, and occasionally in the sub-peritoneal fat 
 or omentum. Its seats of predilection are the limbs, trunk, and neck 
 (Fig. 55). It frequently is fibrous in character, then being firmer 
 than a pure lipoma (Fig. 50). It may be attached })y a j)edicle deep 
 down in a muscular interspace, occasionally to periosteum. ^Mucoid 
 degeneration may occur (my.vo-lipoma) , especially in internal lipomas. 
 
 Diagnosis may be aided by freezing the growth, whereupon it will 
 become hard. 
 
 Treatment. — If any treatment is required, excision should be done. 
 
 Fig. 55. — Lipoma of neck, duration 
 nineteen years. Very soft, almost fluctu- 
 ating. (Not goitre; not attached to 
 larynx; does not rise in swallowing.) 
 Episcopal Hospital. 
 
 Fig. 56. — Fibro-lipoma of right cheek 
 in a girl, aged fifteen years; growing 
 slowly for last nine years. Sight of left 
 eye lost from smallpox in infancy. 
 Episcopal Hospital. 
 
 Xanthoma. — Xanthoma is a small flattened benign fatty and fibrous 
 tumor in the skin, whose nature is not well understood. It is named 
 from its yellow color, occurs most frequently around the eyes, and 
 is sometimes seen in persons' with gall-bladder disease. Usually no 
 treatment is required. 
 
 Fibroma. — Tumors consisting solely of fibrous tissue are rare; they 
 usually are small (Fig. 57), frequently multiple, grow slowly, and are well 
 encapsulated. Depending upon the amount of fibrous tissue present, 
 fibromas are named hard or soft. The latter is the more frequent 
 variety, and is well represented by the mucous polypi growing in the 
 naso-pharynx. The tumor is firm to the touch, pale and glistening 
 on section, with a capsule usually demonstrable. The favorite sites 
 of development are the subcutaneous tissues, along nerve trunks, 
 in periosteum, fascia, the uterus and mammary gland. Some of these 
 must be regarded as fibroid over-growths rather than as distinct tumors, 
 e. g., fibroma molluscum. Fibromas frequently undergo degeneration, 
 
FIBROMA 
 
 109 
 
 Fig. 57. — Fibroma pendulum. Episcopal Hospital. 
 
 particularly tlir iiiucoid, forming' a tiiinor known as myxoma; tliis is 
 
 especially t're(|uent in nnicons [)()lyps; a tnnior in or hetween the 
 
 <j;luteal nnisclcs usnally is a 
 
 fibro-myxoma. Malignant 
 
 elianu'cs arc hy no means 
 
 rare, the cells remainin*;' 
 
 ininiature. and prolit'erat- 
 
 in<;' with niuhie aetivity, 
 
 forniinji; the fibrosarcoma; 
 
 )N!/.ro-.sarr()ni(t also occurs, 
 
 as well as internal hemor- 
 
 rliaii;e with cyst formation. 
 Dlaf/nosis. — Diagnosis is 
 
 made 1)\' notinji; the long 
 
 duration; indolent growth; 
 
 firm consistence; rounded, 
 
 apparently encapsulated 
 
 character; and normal 
 
 overlying skin. 
 
 Treatment. — Frequently 
 
 none is required; but any 
 
 suspicion of malignancy 
 
 (Fig. 58), arousefl by rapid growth, apparent myxomatous or cystic 
 
 changes, etc., justifies prompt extirpation. Recurrence is not very 
 
 rare, even after removal of an apparently benign tumor, and, as a 
 
 rule, the recurrent is more malignant than the primary growth. 
 
 Keloid or Cheloid. — The hyper- 
 trophied condition of scars, known as 
 the keloid of Alihert,^ is really a form 
 of fibroma affecting the subepithelial 
 tissues. It almost invariably follows 
 some irritation, though individual 
 predisposition has much to do with 
 its development. Thus it is often 
 seen in the negro race (Fig. 59); it 
 may develop in the scars of burns, or 
 of comparatively simple operations 
 (Fig. 60). There is some evidence 
 that it is of tuberculous origin. It 
 is a crab-like (keloid) or scar-like 
 (cheloid) out-growth, covered by 
 red, tense, shiny epithelium; it may 
 extend into sound tissues in various 
 directions. It usually is tender, and 
 
 irritation increases its size. Occasionally the out-growths disappear 
 
 spontaneously; they usually recur after excision. 
 
 1 To distinguish it from the Keloid of Addison (Morphoea), an affection belonging 
 rather to dermatology than surgery. 
 
 Fig. 58. — Fibroma of back, malig- 
 nant degeneration. Patient aged 
 seventy-three years; duration fifteen 
 years. Episcopal Hospital. 
 
no 
 
 TUMORS 
 
 Treatment. — Treatment consists in protecting them from irritation 
 by the clothes or opposing parts of the body. Ointments of tar and 
 
 zinc, with animal rather than 
 mineral bases, are valuable. 
 Thiosinamin (5 to 10 per cent, 
 solution) hypodermically, is 
 recommended by Park (1907). 
 Chondroma. — A tumor com- 
 posed chiefly of cartilage. If 
 it springs from preexisting 
 cartilage cells it is termed 
 ecchondroma (cartilaginous 
 out-growth); if from other 
 forms of connective tissue, 
 especially fibrous, it is called 
 enchondroma (cartilaginous 
 tumor). Its occurrence as a 
 terato-blastoma was referred 
 to at p. 106. Chondromas are 
 of stony hardness, unless de- 
 generated; usually more or 
 less lobulated, grow slowly, 
 but usually faster than lipomas 
 or fibromas, the growth occur- 
 ring chiefly at the periphery; 
 are painless, immovable, fre- 
 quently multiple ; seldom affect 
 the overlying skin; and are generally quite benign, but liable to form 
 metastases. They are especially prone to mucoid degeneration, and 
 when such occurs malig- 
 nancy should be suspected. 
 Sarcomatous changes are 
 not unusual. True bony 
 changes (osteo-chondroma) 
 sometimes occur. If the 
 skin sloughs, the cystic 
 contents of the degener- 
 ated chondroma may dis- 
 charge, leaving a most 
 intractable sinus. 
 
 Ecchondromas arise from 
 epiphyseal lines before 
 adult life, and later also 
 from articular, costal, and 
 intervertebral cartilages, 
 larynx, trachea, etc. En- 
 chondromas spring from 
 from articular cartilages, 
 cially in the rachitic; affect especially the phalanges, the flat bones 
 
 Fiii. 39. — Keloid (of Aliheit J in scars following 
 a whipping from patient's mother. Patient of 
 the late Dr. Isaac Massey, of West Chester, Pa. 
 
 Fig. 60. — Keloid in .scar of neck. Had lirush burn 
 in 1907, and keloid was excised one month later. 
 Keloid recurred, and present photograph made one 
 year after recurrence. Episcopal Hosjiital. 
 
 periosteum or bone marrow, but not 
 Chondromas develop in early life, espe- 
 
OSTEOMA 
 
 111 
 
 ({ielvis, scapula, skull), the fcnuir, aud tlu' uiaxilla. When growiiifj^ 
 on tho surfaci' of a bono, beneath the ixTiosteuni, they may wear away 
 its surface, leaving a distinct (le])ressi()n when they are removed. 
 
 Diagnosis. — They are to be distinguished from bony tumors by 
 their occurrence in younger patients, by their situation, and by their 
 multiplicity; but a differentiation is not always i)ossible without the 
 •T-rays. Cartilage casts no shadow, or at most a very light one. 
 
 Treatment. — Chondromas should be completely extirpated when- 
 ever possible. Incomplete removal favors recurrence, and the recur- 
 rences are more inclined to malignancy than the primary growths. 
 Amputation, except of the phalanges, is rarely required. 
 
 Osteoma. — A true tumor com- 
 posed solely of bone is decidedly 
 rare; most so-called bony tumors 
 are really only osseous hypertro- 
 phies. True osteoma may ari.se 
 on the surface of, or within the 
 substance of bone. In the former 
 
 Fig. 61. — Multiple ecchondromas of 
 finger. (Shepherd.) 
 
 Fig. 62. — Osteoma of upper jaw. Four 
 years' standing. From a patient in the 
 University Hospital under the care of the 
 late Prof. John Ashhurst, Jr. 
 
 instance it grows beneath the periosteum ; in the latter it grows from 
 the medulla, being then known as endosteoma. Either form may 
 be composed of spongy or of compact bone. The tumor grows by 
 cellular proliferation of its own elements, not from participation of 
 elements in the surrounding bone; these latter are compressed, pushed 
 aside, and eventually disappear before the ongrowing tumor. Thus 
 a periosteal osteoma will excavate the underlying bone, while an 
 endosteoma will penetrate it, break through the cortical bone, and 
 grow more freely when thus reheved from pressure. Occasionally an 
 
112 TUMORS 
 
 osteoma occurs in tissue which normally contains no bone. Such a 
 tumor is a heteroplastic osteoma; it is possible that it develops from 
 a fetal milage, but usually it arises in a piece of cartilage or periosteum 
 which has been displaced by trauma in post-natal existence. That 
 true bone can form in chondromas has already been noted. 
 
 Ostoses. — A diffuse bony out-growth is called a hyperostosis; a cir- 
 cumscriljed, more or less sessile out-growth is an exostosis; a projecting 
 growth with narrow base is an osteophyte; while an osseous out-growth 
 occurring in the centre of a bone (e. g., arising from the diploe) is termed 
 an endostosis or enostosis. Occasionally an ostosis of one form or 
 another appears to become neoplastic in nature, exhibiting autonomous 
 proliferation. Exostoses, which are the most frequent of the bony 
 hyperplasias, usually are multiple, and very difficult to distinguish 
 from multiple ecchondromas, especially as ossifying changes in the 
 latter are l)y no means rare. They occur in the same situations (except 
 that exostoses are very rare on the hands), present the same charac- 
 teristics, and run the same clinical course. The imry exostosis of the 
 skull is an exception, which it is usually possible to distinguish 
 clinically. It is extremely hard, and if growing from the diploe 
 (enostosis) may be as prominent on the dural as on the pericranial 
 surface. Ostoses are sometimes developed in the accessory sinuses of 
 the face. Bony changes occurring in tendons, muscles, etc., are referred 
 to at p. 274. 
 
 Diagnosis. — Diagnosis, especially of endosteomas and enostoses, 
 may be impossible without the use of the a'-rays, by which the denser 
 shadow of osseous growths may sometimes be distinguished from that 
 cast by cartilaginous tumors. 
 
 Treatment. — Rarely is any required, unless removal of one or more 
 circumscribed out-growths is necessary to relieve pressure on nerves, 
 bloodvessels, the brain, etc. Recurrence after thorough extirpation 
 is exceptional. 
 
 Odontoma. — The teeth are developed from epiblast and mesoblast, 
 and while a tumor having its origin in either element may occur in 
 man, the vast majority of odontomas are derived from the epithelial 
 portion, and are seen as "cysts lined with columnar or cuboidal 
 epithelium or containing gland-like areas in their w^all" (Simmons, 
 1907). This form, known also as adamantinoma, usually springs from 
 the lower jaw, the tumor growing in and slowly distending the body of 
 the bone ; it is composed of multilocular cysts, with a bony framework 
 (multilocular dentigerous cyst) . It occurs especially in young females, 
 is of slow growth, and usually symptomless except when causing pres- 
 sure on neighboring parts. Crackling may be detected on palpation 
 if the growth has thinned the overlying bone. Usually there is an 
 unerupted tooth present. 
 
 Diagnosis.- — Diagnosis sometimes is difficult, especially from sar- 
 coma. Carcinoma is more frequent on the upper jaw in older patients, 
 and ulceration is common. Exostoses and chondromas are denser and 
 the .r-ravs max reveal the cvstic nature of the adamantinoma. Sarcoma 
 
MYELOMA 113 
 
 in this sitiuition usually is periosteal in orij^in, grows rapidly, c|uickly 
 invades the soft parts, is not cystic, and presents no "egg-shell" 
 crackling. 
 
 Trcaiiiicnt. — Opening the growth, and destroying its interior tiior- 
 onghly with the shar]) spoon and actual cautery, usually effects a cure. 
 It is essentially henign. The o})eration may be done from within the 
 mouth. 
 
 Myeloma. — The bone marrow contains two chief varieties of cells — 
 those having to do directly with bone, and those supplying the blood. 
 Adami classes under this section tumors derived from true bone 
 marrow (osteogenetic) cells, and certain blastomatoid conditions due 
 to disturbances of the l)lood cell elements in the marrow. 
 
 Giant-ccUcd Myeloma. — ^This, frequently spoken of as giant-celled 
 sarcoma, is too little malignant to be classed with atypical hylic tumors. 
 It is composed of large numbers of myeloplaxes (giant cells of bone 
 marrow) lying in a matrix formed by spindle or polygonal cells of fibro- 
 blastic tyj)e. The tumor may develop beneath periosteum, sometimes 
 occurs in the lower jaw or cla\'icle, but usually arises in the interior 
 of the shafts of long bones, near the epiphyses; it is almost the only 
 tumor found in the radius; it occurs in the young, grows slow^ly, and 
 expands the overlying bone, which may become so thin as to crackle 
 on pressure {sj/ina ventosa). The tumor itself is rather soft, quite 
 vascular, and when sectioned resembles splenic tissue or even currant 
 jelly; if it breaks through its bony capsule pulsation and occa- 
 sionally bruit are present {false osteoid aneurysm) . (See p. 446.) Spon- 
 taneous fracture is rare. The lymphatic system is not affected in 
 pure myeloma; no metastases occur; and if the tumor is thoroughly 
 removed recurrence is unlikely. Occasionally, however, the tumor 
 undergoes sarcomatous change, the stroma cells being small, growth 
 rapid, and recurrence usual. 
 
 Diagnosis.- — A slowly growing tumor, in the interior of a bone, 
 and near the epiphysis if in a long bone, occurring before twenty-five 
 years of age, and not producing cachexia or metastasis, is usually a 
 giant-celled mveloma. The diagnosis from bone cvsts is discussed at 
 p. 446. 
 
 Treatment. — Usually it is sufficient to cut aw^ay the overlying bone, 
 clean out the tumor tissue, scrape and thoroughly cauterize the walls 
 of the cavity; but it is safer in case of recurrence to excise the whole 
 end of the bone affected. Amputation should be done for invasion 
 of the soft parts. 
 
 Myelomatosis. — This blastomatoid condition effects the red bone 
 marrow chiefly of the vertebrae, ribs, and cranium; it is a primary 
 nwltiple process (Borst). The growths are yellowish red, pulpy, and 
 firm, and though it is due (Adami) to proliferation of the blood-forming 
 elements of the marrow, there is in orthodox cases no involvement 
 of the lymphatic system or spleen (such a condition being called 
 myelogenous leukemia). Albumosuria (Bence-Jones) is frequent in 
 myelomatosis, and relations of this disease to osteomalacia are not 
 
114 TUMORS 
 
 clear. Treatment is sometimes required because out-growths in the 
 vertebrae press on the cord; excision should be done. 
 
 Chloroma. — Chloroma, according to Adami, is an aberrant type of 
 myelomatosis; it is a rather malignant, multiple growth of greenish- 
 yellow tint, affecting especially the face bones; and is frequently 
 associated with myeloblastic leukemia (Dock). 
 
 Lymphomatosis. — As myelomatosis is due to proliferation of blood- 
 forming marrow cells (myeloblasts, which produce leukocytes), so 
 lymphomatosis is a corresponding state due to hyperplasia of lympho- 
 blasts. There are many affections characterized by widespread 
 enlargement of lymphatic tissue, notably tuberculosis; there are others, 
 probably, but not certainly tuberculous; and there is Hodgkin's 
 disease, of unknown cause (p. 271); levkemia is still another, but has 
 no surgical interest. Adami, in addition to the above blastomatoid 
 conditions, admits the existence of typical lymphoma; but far more 
 frequent is atyjncal lymphoma, comprising the various forms of lympho- 
 sarcoma (p. 272). 
 
 Myoma. — The leiomyoma is a tumor composed of smooth muscle 
 fibres, arranged in various directions, and inclosed in a fibrous stroma 
 (fibromyoma). The older the tumor the more does fibrous tissue 
 preponderate, so that finally muscular fibres may be inconspicuous 
 (fibroids) ; this change may be a mere over-growth of fibrous tissue, or 
 an actual metaplasia of muscle fibres (Adami). It occurs with over- 
 whelming frequency in the uterus (p. 1102), but occasionally is found in 
 other portions of the genito-urinary system or in the digestive tract, 
 where the stomach is most often affected (49 cases collected by Deaver 
 and Ashhurst in 1909). The tumors are usually multiple, may attain 
 immense size, and frequently require excision. 
 
 Rhabdomyoma. — The occurrence of this tumor, except in connec- 
 tion with terato-blastomas (p. 100), is almost unknown. It appears 
 usually to be malignant. 
 
 Neuroma. — A true ganglionar-celled neuroma is so rare as to be of 
 no interest surgically. False neuromas are fibrous "out-growths" 
 occurring upon nerves (fibromatosis nervorum). Amputation neuromas 
 are somewhat similar (p. 200). 
 
 Glioma. — This is a tumor developed from the stroma of nerve 
 tissue (neurogha) (Fig. 63) ; it is found, with few exceptions (retina, 
 cerebral nerves), in the brain; and may be either hard (when pro- 
 jecting into the ventricles) ; or soft, when it infiltrates the cerebral 
 hemisphere without any attempt at encapsulation fp. 582). 
 
 Chordoma. — Chordoma is a rare tumor growing from bone in the 
 region of the pituitary body, and developed from remains of the noto- 
 chord. 
 
 Atypical (Malignant) Hylic Tumors. — Sarcoma. — The characteristics 
 of malignancy in general (p. KJoj and of atypical blastomas in par- 
 ticular (p. 107) have already been considered. Sarcomas are atypical 
 hylomas of mesenchymal origin, all possessing this peculiarity, that 
 they are composed of embryonic connective tissue cells. Sarcoma 
 
SARCOMA 
 
 115 
 
 may, therefore, occur wherever connective tissue exists; indeed, as 
 pointed out by Bland-Sutton (1906), it may be regarded as a malig- 
 nant tumor disease of connective tissue. Sarcoma occurs by prefer- 
 ence, however, in bone, periosteum, fascia, ligaments, tendons, brain, 
 ovaries, testicles, and skin; less often in the lungs, muscles, uterus, 
 liver, and intestines. It grows rapidly, by cellular proliferation in all 
 parts of the tumor, frequently assumes a lobular appearance, infiltrates 
 in all directions, particularly along and inside of bloodvessels, and 
 early gives rise to metastasis through the blood-stream. Though 
 most sarcomas infiltrate equally in all directions, certain tumors extend 
 in finger-like processes here and there, giving an organoid appearance 
 to the section. Such growths have been termed alveolar and tubular 
 sarcomas. A special characteristic of all sarcomas is the extreme 
 
 
 Fig. 63. — A, from the more typic'al portion of a glioma. B. Another region from same 
 growth of more malignant type, a true gliosarcoma. (Thomas and Hamilton.) 
 
 meagreness of the stroma present; only with difficulty may stroma 
 be detected", so closely are the sarcoma cells packed together. Sar- 
 comas are highly vascular, and the walls of the bloodvessels are com- 
 posed solely of endothelial cells; the sarcoma cells lie in immediate 
 contact with the outer surface of the endothelium, and frequently 
 grow inside the vessels. A characteristic of rapid growth and of 
 the vascularity of these tumors is their liability to myxomatous and 
 other degenerations, to internal hemorrhages, and to cyst formation 
 (p. 103). 
 
 Sarcomas are classified according to the form and size of their 
 component cells into small round-celled, large round-celled, and spindle- 
 celled sarcomas (Fig. 6-1 and 65); or, where several kinds coexist, 
 mixed-celled sarcomas. The smaller the cell and the less the amount 
 
116 
 
 TUMORS 
 
 of stroma, the more malignant is the sarcoma; therefore, the large 
 spindle-celled sarcoma (formerly called "recurrent fibroid") is the 
 least malignant, probably because in the others the cells are less 
 developed, the most so in this. The form of the sarcoma cell 
 depends on the structure from which it is derived; thus, as pointed 
 out by Adami, only cells Avhich, in the course of their normal develop- 
 ment,*^ pass through a spindle-celled stage can give rise to spindle- 
 celled sarcoma (connective tissue cells, plain muscle fibres, etc.); 
 whereas round-celled sarcomas are developed from cells such as 
 lymphocytes, which even when normally matured are still round. 
 Finally, calling the above 2^i<re sarcomas, a group of iritermediate 
 sarcomas may be recognized, in which some of the cells develop beyond 
 the embryonal stage sufficiently to give a tissue characteristic to the 
 tumor, but do not reach full adult maturity: /tro^arcow? a, lympho- 
 sarcoma, osteosarcoma, chondrosarcoma, gliosarcoma, etc. 
 
 
 wwKmz-f%^. 
 
 |9©^ 
 
 
 &&'hs. 
 
 he. 
 
 ^r^^ 
 
 Fig. 6-i. — Small round-celled sarcoma 
 from skin. (High magnification.) (From 
 Professor Klotz.) 
 
 Fig. 65. — Spindle-celled sarcoma (recur- 
 rent, from forearm) : a, delicate-walled 
 bloodvessel in tumor. (From Professor 
 Klotz.) 
 
 It is an interesting question, as yet undecided by pathologists, 
 whether the term sarcoma shall be applied to a tumor composed of 
 any cells other than connective tissue cells. Thus, if, for example, a 
 sarcomatous tumor is found in (smooth) muscle tissue, it may have 
 originated (1) by sarcomatous proliferation of the connective tissue 
 cells (not muscle cells) in the tissue of a normal muscle or of a typical 
 leiomyoma (p. 114); (2) by malignant proliferation ah initio of the 
 muscle cells themselves; or (3) by a secondary sarcomatous change 
 (anaplasia) aflPecting the muscle cells in a previously formed myoma. 
 To the first tumor the name myosarcoma is properly applied; the 
 second, which many hold is not truly a sarcoma, is best described as 
 a malifjnant myoma; while the third is distinguishable from the others 
 by the term myoma sarcomatodes. According to Adami, this last is 
 
SARrOMA 
 
 117 
 
 pr{)l)al)ly the most frequent form; but most i)atlu)l()sists, I believe, 
 still roj^artl the first as the most usual. The same question arises in 
 connection with <i;lionia, lyi)h()ma, endothelioma, etc., and also with 
 osteosarcoma, fibrosarcoma, etc., thouffh not so i)ointcdly in these 
 latter, because they are formed of connective tissue alone. 
 
 Diagnosis. — Sarcoma occurs usually in the young (over forty years 
 it is quite rare), not infrequently follows trauma, grows rapidly 
 (weeks and months), causes early metastasis, especially in the lungs 
 and skin; is frcciuently hot, and painful; and eventually produces 
 cachexia. It is firm but not bony to the touch if growing from bone 
 or cartilage; rather soft if in fibrous tissue or the viscera. 
 
 Fig. 66. — Inoperable sarcoma of pelvis; rapid growth after exploratory laparotomy 
 six months ago. Note ecchymosis of hip from recent bruise. Children's Hospital. 
 
 Prognosis. — This is gloomy. Recurrences are almost inevitable; 
 and even if no recurrence occurs locally, visceral metastases, unde- 
 tected at time of operation, almost surely kill within two or three 
 
 vears. 
 
 Treatment. — Prompt extirpation, which often but not always 
 implies amputation of the limbs, and wide cutting excision of other 
 parts, offers the only chance of cure. Reoperation for local recur- 
 rences sometimes prolongs life, though rarely effecting a cure. If 
 the tumor is inoperable when first seen, treatment with Coley's fluid 
 should be tried; and in all cases it is well to use this after operation. 
 The mixed toxins of the B. prodigiosus and streptococcus, introduced 
 by Coley of New York in 1892, are administered hypodermically, 
 either into the growth itself or its immediate neighborhood (initial 
 dose I to ^ a minim), or in other parts of the body (initial dose 1 
 minim), the dose gradually being increased so that it is no more than 
 sufficient to cause febrile reaction analogous to that seen with tuber- 
 culin (p. 81). It has been a clinical observation for nearly fifty 
 years that attacks of erysipelas occasionally had a healing influence 
 on malignant growths; and it is not an illogical theory that bacterial 
 toxins might influence tumor cells favorably, reducing the process 
 more nearlj'^ to that of an inflammatory reaction. As a matter of 
 fact, the use of Coley's fluid, especially in his own hands, has secured 
 some surprisingly favorable results: in a few instances permanent 
 
118 
 
 TUMORS 
 
 cure has followed; in many the tumors have been reduced to operable 
 states, or have been kept in abeyance, as it were, for sometimes they 
 grow again when treatment is discontinued; in some, recurrence 
 seems to have been prevented. My own experience with Coley's 
 fluid has been very limited, but on the whole favorable; the tumor 
 has at least grown smaller, and the pain and discomfort of the patient 
 been noticeably relieved. 
 
 Typical (Benign) Lepidic Tumors. — PapUloma. — This is an epithelial 
 tumor growing from skin or mucous membrane (Fig. 50). It projects 
 above the surface, sometimes as a single nodular mass, sometimes as a 
 definitely papillomatous out-growth. Its nourishment is derived from 
 vessels which are carried to it in a core of the underlying connective 
 
 Fig. 67. — Papilloma of bladder to 
 show the long, finger-like papillomatous 
 outgrowths. (Ribbert.) 
 
 Fig. 68. — Intracystic papilloma of breast. 
 (Orth.) 
 
 tissue; but the connective tissue itself typically undergoes no 
 blastomatous change, merely growing as required by the inde- 
 pendent growth of overlying epithelium. Most so-called papillomas 
 (warts, etc., p. 259) are clearly not neoplasms, but hyperplasias due 
 to chronic irritation. Some of the mucous polypi described as soft 
 fibromas (p. 108) may be considered as forms of papilloma, if it is the 
 epithelium and not the connective tissue core which becomes blasto- 
 matous; the question is very hard to decide. True papillomas occur 
 chiefly on mucous surfaces, especially the urinary bladder, where the 
 tumor is composed of numerous fine finger-like projections (Fig. 
 67); stomach (polyposis); rectum; uterus, etc. Similar tumors often 
 grow from the mucous lining of cysts, especially in cystic adenomas 
 {intracystic ■papillomas) (Fig. 68). 
 
CARCINO\fA 119 
 
 Treatment. — As malignant changes (carcinoma) are not very un- 
 common, papillomas arc best treated by excision; and, unless this is 
 thorough, recurrence is frequent, es})ecially in the bladder. 
 
 Adenoma.^ — Instead of the lining membrane presenting out-growths, 
 as in the case of i)ai)illoma, in-ijrotrths may occur; as this cliange is 
 almost limited to preformed glands, the resulting neoplasm is called 
 an adenoma. It is not a very common tumor, being encountered 
 most often in the mamma, thyroid, liver, prostate, and around the 
 margins of gastric ulcers. In the two latter situations it is j)robable 
 that the change is one of adenomatosis, a hyperplastic reaction to 
 chronic irritation. The more important adenomas are discussed in 
 connection with transitional lepidomas (p. 127). The true adenoma 
 probably always originates in cell rests; it is well encapsulated, and 
 has no conununication through ducts with the excretory channels of 
 the gland in which it lies. The cells forming an adenoma usually 
 retain some of their glandular characteristics, and may secrete a 
 modified form of the natural product; this secretion then distends the 
 acini, and a cysiadenoma is produced. Into these cysts papillomatous 
 growths frequently occur (Fig. 68), producing intracystic ijainlloma; 
 or cystadenoma j^ciinlliferwn. Here again it is exceedingly difficult 
 to tell whether the projectioxis are truly papillomatous or whether 
 they are only apparently papillomatous, being caused by the adjacent 
 in-growth of adenomatous cells. In many adenomas the fibrous stroma 
 is markedly increased {fibroadenoma), and it is held by some that 
 neoplastic proliferation of this stroma is the cause of the papilloma- 
 tous intracystic projections, and that the epithelium overlying the 
 projections is entirely passive. The cells of an adenoma always lie 
 upon a well developed basement membrane, which invariably sepa- 
 rates them from the underlying stroma ; when the tumor grows rapidly 
 this basement membrane may be poorly developed; and when it is 
 absent, and the epithelial cells have broken through, lying in immediate 
 contact with the stroma, the tumor can no longer be considered an 
 adenoma: it has undergone malignant (carcinomatous) change. Bland- 
 Sutton (1906) denies that such a change ever occurs. An adenoma 
 may be very small, or extremely large and ponderous; the smaller, 
 harder, tumors of the breast are usually painful. 
 
 Treatment. — Adenomas should be removed whenever possible; espe- 
 cially does rapid growth render this imperative. Recurrence is not 
 to be feared; and metastasis is unknown. 
 
 Atypical (Malignant) Lepidic Tumors. — Carcinoma. — This includes 
 all malignant tumors of epiblastic or hypoblastic origin. Under 
 carcinoma of epiblastic origiji are included all skin cancers, as well as 
 cancers derived from the mammary and other epidermal glands, 
 epithelium of mouth, salivary glands, naso-pharj^nx, etc.; while those 
 of hypoblastic origin include carcinoma of the digestive tract, pancreas, 
 liver, bladder, and respiratory tract, thyroid, thymus, tonsils, etc. 
 Although the cause of carcinoma is totally unknown, most cases occur 
 in persons over forty years of age, and it is most frequent in sites 
 
120 TUMORS 
 
 which have h)ii^ been su})jected to irritation, or in which unhealed 
 and chronically irritated ulcers exist — e. g., lacerations of the cervix 
 uteri, gastric ulcer, smokers' cancer of the lower lip, syphilitic ulcers 
 of the tonj^ue, chimney-sweep's (soot) cancer of the scrotum, cancer of 
 the skin in workers in paraffin, pitch, chrome, etc. 
 
 Carcinoma is due to the independent (autonomous) growth of epi- 
 thelial cells; and this growth is atypical. That is to say, it differs not 
 only from the growth of epithelial cells seen in regeneration (healing 
 of ulcers), but it also differs from the growth of epithelial cells seen in 
 an adenoma. In an adenoma, for instance, the epithelial cells retain 
 to a certain degree their normal character; they line the gland tubules 
 or acini, leaving usually a distinct lumen, and rarely forming more 
 than one layer around this central lumen; and they are always placed 
 on a distinct l;asement membrane. In carcinoma, on the other hand, 
 the in-growths of epithelial cells are usually solid, finger-like masses; 
 there is no lumen, except in certain cancers derived from preformed 
 glands, and even then the cells tend to pile upon each other around 
 the periphery and to encroach on the lumen; the basement mem- 
 brane is absent, and the masses of epithelial cells are in direct contact 
 with the surrounding tissues. When seen in cross-section it appears 
 as if there were cell nests entirely detached, lying in the connective 
 tissues; but rarely, if ever, is this the case. It has been shown by serial 
 sections (Petersen) that these are directly continuous with the sur- 
 face epithelium, being one of the claws of the crab-like growth which 
 gives cancer its name. 
 
 Not only does carcinoma extend in all directions into all surround- 
 ing tissues, but it has a very extraordinary tendency to extend along 
 lymphatic channels. It was formerly thought that this extension was 
 largely in the way of metastasis, i. e., that groups of carcinoma cells 
 were detached from the main tumor and carried in the lymph current 
 away from their site of origin, until, lodged in the nearest lymph nodes, 
 they there set up a metastatic growth entirely separate from the main 
 tumor, leaving uninvolved tissue between. That this sometimes occurs 
 may not be denied, but it is certain, owing chiefly to the researches 
 of Handley (1905) in relation to mammary carcinoma, that in the 
 vast majority of cases such extension occurs by direct continuity 
 (permeation) along the lymphatic spaces of the deep fascia, and along 
 lymph vessels, and that the affected lymph nodes are connected icith 
 the primary tumor by innumerable fine cords of carcinoma cells. When 
 the lymph nodes are invaded, dissemination beyond them may occur, 
 the carcinoma cells eventually entering the blood-stream and being 
 widely disseminated in the lungs, spine, etc. Occasionally, dissemina- 
 tion by the blood occurs early, before the adjacent lymph nodes are 
 palpably affected. These secondary growths, wherever found, repro- 
 duce the character of the primary tumor; we may find in the humerus 
 a secondary nodule with the characteristics of the glands of the rectum, 
 nodules in the ovary with the features of the mammary gland, etc. 
 Secondary deposits are rarest in muscle, most frequent in the skin, 
 
EPITHELIOMA 
 
 121 
 
 lun^s, and bono, especially the vertebrie, as well as in organs anatoniie- 
 ally related to the j^riniary f^rowth. 
 
 Two main varieties of carcinoma may he reco<,nii/,ed: J-'/jilliclioiiKi 
 and (I'ldiidiilar ('(irriiioiiia. 
 
 Epithelioma. Thou^di this term is ajjplied hy the French to all 
 malignant tumors of ei)ithelial origin, it is customary among P^nglish 
 speaking surgeons to limit it to squamous-celled carcinoma, and it is 
 so used in this volume. It affects the skin, especially muco-cutaneous 
 junctures (lips, anus, glans penis, vulva), mouth, tongue, pharynx, 
 eso])hagus, etc. \'ery exceptionally epithelioma has heen found where 
 no squamous epithelium normally exists (gall-hladder, stomach, 
 uterus, etc.). Pre-rancrroiis changes are well recognized clinically. 
 Among those of most importance are the senile or seborrheic patch 
 {hrrafosis, p. 0-2); lenloplakia (p. (547); and Paget' >> di.s-ca.se (p. 719). 
 As already noted, any chronic irritation seems to pre(iisj)ose to the 
 development of carcinoma. 
 
 Two forms of epithelioma are distinguishable, the superficial, and 
 the deep-seated, of which the last will be described first. 
 
 
 m^ 
 
 
 
 ■■■: ?) 
 
 \*'y^f," ■ ■ '■■'■'. ■- 
 
 ■■::00::B: 
 
 
 
 
 
 
 Fig. 69. — Early epithelioma of tongue, to show (a) region of origin by down-growth 
 from preexisting epithelium; h b, epithelial pearls; c, small-celled infiltration in sur- 
 rounding tissue. (Petersen.) 
 
 1. Deep-seated Epithelioma. — This, the more frequent variety, 
 commences as a downward proliferation of epithelial cells which 
 preserve fairly well the typical appearance of cells of the rete 
 
122 
 
 TUMORS 
 
 Malpighii, a few "prickle" cells frequently being discernible. These 
 cells are very slightly anaplastic: they preserve their functions so far 
 that they still tend to undergo horny changes, this keratosis resulting 
 
 in the formation of "pearly 
 bodies," which are really cross- 
 sections of plugs in which the 
 central cells have become horny,, 
 and being compressed by those 
 outside, produce a typical lami- 
 nated appearance (Fig. 69). A 
 little round-celled infiltration 
 may be seen around these in- 
 growths, evidences of reaction 
 on the part of the stroma. 
 
 This form of epithelioma when 
 growing on the skin usually is 
 first noticed by the patient as 
 an induration (hyper-keratosis), 
 commencing frequently in a 
 senile seborrheic patch (p. 622). 
 Or it may develop from a papil- 
 loma (Fig. 70). Soon the centre 
 becomes abraded, crusts, ulcer- 
 ates, and gives thfe growth an 
 umbilicated appearance (Fig. 
 71). This ulcer spreads; its 
 edges may retain the features of 
 the original nodule, but usually are less firm, ragged, and only moder- 
 ately raised above the base of the ulcer. It occurs especially on the 
 face and hands, the lower lip 
 being a favorite site. The 
 neighboring lymph nodes are 
 invaded early (three to five 
 months), and the progress of 
 the disease is much more rapid 
 than that form about to be de- 
 scribed. The stench from these 
 ulcerated surfaces is some- 
 times frightful, and alarming 
 hemorrhages may occur in the 
 later stages. Occasionally, 
 early in the course of the dis- 
 ease, the ulcer is covered with 
 warty excrescences (Papillary 
 Epithelioma) (Fig. 72), form- 
 ing one variety of Marjolin's ulcer (p. 58) ; but these warty granulations 
 often disappear as ulceration progresses. 
 
 Diagnosis. — This will be considered more in detail in the chapters 
 devoted to regional surgery. Any chronic ulcer of the skin or adjacent 
 
 Fig. 70. — Epithelioma of nose; aged sixty- 
 three years; duration one year. (Developing 
 in a papilloma.) Episcopal Hospital 
 
 P"iG. 71. — Epithi'liomaof hand; aged seventy- 
 eight years; duration one year. Note um- 
 bilicated appearance. Episcopal Hospital. 
 
CLASSIFICATION OF TUMORS 
 
 123 
 
 niiu'ous membranes should be regarded witli siis])i('ion. Epithelioma 
 in leg ulcers, though very umi.sual, is sometimes seen; it is less infre- 
 quent in the heel. 
 
 J*r()(/it(n>is is good if excision is done early, before lym])li nodes are 
 I)alpably enlarged; later, recurrence is frequent. 
 
 Treatment. — Early excision, in one mass with the adjacent lymph 
 nodes and all intervening sul)cutaneous tissue, is the only form of 
 treatment which offers hope of perman- 
 ent cure. If an operation is contra- 
 indicated for any good reason, the 
 .r-rays may be applied, and in the very 
 earliest stages the ulcer sometimes heals 
 under their influence; but recurrence is 
 usual, and by dilly-dallying with .r-rays 
 the favorable time for excision may be 
 lost. In some inoperable cases of ex- 
 ternal carcinoma relief may be secured 
 by desiccation with the high frequency 
 current, or by fulguration. The former 
 is suitable only for surface growths, 
 while fulguration is more useful for 
 deeply seated tumors after eurettement 
 or partial extirpation. 
 
 2. Superficial Epithelioma (Ro- 
 dent Ulcer, Jacob's Ulcer). — This 
 was first described as a clinical entity 
 by Jacob of Dublin in 1827. It was 
 first recognized as a variety of carcinoma 
 by Warren in 1872. i 
 
 The epithelial cells which grow down from the skin are extremely 
 atypical, rounded, polygonal, or even spindle-shaped. Because they 
 do not form "epithelial pearls," Krompecher (1903) has named this 
 type of epithelioma "basal-celled carcinoma," on the theory that it 
 is the only type formed from basal cells; but Adami contends that all 
 epitheliomas are so formed, and that whereas in all others the cells 
 develop to the horny stage, in the rodent ulcer the cells are unable 
 to do so because they present a higher degree of anaplasia. 
 
 The favorite site of rodent ulcer is on the upper half of the face, 
 especially near the ala nasi, on the lower eyelid, or the forehead; it 
 is almost unknown on other parts of the body. It is often preceded 
 by changes in the skin (keratosis,- etc., see p. 622) of an irritative 
 character, and rarely is recognized until a small ulcer has formed, 
 scabbed over, and again become ulcerated several times. The ulcer 
 spreads very slowly, gives little discharge, is painless; has raised, firm, 
 glistening edges; and occasionally heals in one part while extending 
 
 Fig. 72. — Papillary opithelioma 
 (superficial epithelioma lately show- 
 ing more malignant characteris- 
 tics); aged seventy years; duration 
 five years. Episcopal Hospital. 
 
 ^ Borst and other pathologists class it as an endothelioma or alveolar sarcoma. 
 
124 
 
 TUMORS 
 
 in another (serpijjinous ulceration). It does not attack the neighbor- 
 ing lymph nodes, and, contrary to what would be expected from its 
 high grade of anaplasia, is in general much less malignant than the 
 deep-seated epithelioma just described; but it destroys, surely if 
 slowly, everything in its course — eating away cartilage, bone, con- 
 tents of the orbit, opening the nasal cavities and sometimes exposing 
 the brain, before death comes. Sometimes, after progressing slowly 
 for many years, the rodent ulcer will suddenly take on rapid growth, 
 and assume the character of a deep-seated epithelioma (Fig. 72). 
 
 Fig. 73. — Rodent ulcor invading or- 
 bit, in a woman, aged thirty-five years; 
 duration eighteen months. (Dr. W. 
 Walker's case.) Episcopal Hospital. 
 
 Fig. 74. — Rodent ulcer; duration over 
 five years. Eye destroyed. Had so far 
 only x-ray treatment. Now inoperable. 
 Episcopal Hospital. 
 
 Diagnosis. — It must be distinguished chiefly from the deep-seated 
 epithelioma. In rodent ulcer the edges are harder, more raised, 
 glistening, and sometimes covered with fine capillaries; the base of 
 the ulcer is flatter and not so deeply placed; secretion is less; growth 
 is much slower; the lymph nodes are not invaded; and microscopical 
 examination of an excised portion will show no pearly bodies, and 
 extremely atypical cells. 
 
 Prognosis is good with proper treatment sufficiently early. 
 
 Treatment. — Excision should be done, but it is not necessary to 
 remove the adjacent lymph nodes. Even in advanced cases com- 
 plete excision is seldom followed by recurrence, so that operation 
 should not be refused in any case where reco^'ery from the operation 
 itself seems certain. Very early treatment, by an expert, with radium 
 emanations, frequently causes the ulcer to heal without visible scar; 
 but recurrence is not unknown. The remarks as to .r-ray treatment, 
 made at p. 12.3, apply here. The patient shown in Fig. 74 had been 
 treated for five vears with the .^■-ra^■s before she came to me for 
 
GLANDULAR (AliClXOMA 125 
 
 surgical a(l\ico; she tlien was a confirmed alcoholic and niorphiiio- 
 maniac, and the tumor was absolutely ino|)ral)le. 
 
 Glandular Carcinoma. — This is so-called because it grows in glands. 
 Two forms may be recognized, according to the extent that the tumor 
 departs from the typical glandular form: 
 
 1. Adknocahcinoma. — The less atypical forms, known as adeno- 
 carcinonui, arc composed of alveolar spaces, lined with cells arranged 
 around their periphery, and rarely piling up on each other so as to 
 encroach on the lumen. This form is therefore known also as colvmnar 
 or ri/lindrical-crlird carcinoma (Fig. To). By obstruction of the ducts 
 and continued secretory action of, or from death and liquefaction of 
 the cells, these aheoli may be converted into cysts {cy.stadeno-car- 
 cinoma). It affects especially the rectum, pylorus and lesser curvature 
 of the stomach, cecum, etc., frequently developing from preexisting 
 ulcers or adenomas; or from polypi, when it is wont to assume a 
 cauliflower-like or fungating api)earance. It occurs also, but more 
 rarely, in the cervix uteri, naso-pharynx, larynx, and gall-bladder; 
 also from cell-rests in the neck (})ranchiogenic carcinoma, p. 683). 
 
 ^ 
 
 Fig, 75. — Microscopic appearance of adenocarcinoma (cylindrical-celled 
 carcinoma) of the rectum. (Lexer-Bovan.) 
 
 2. Solid-celled Carcinoma. — The most atypical form of gland 
 carcinoma consists of solid j)lugs of epithelial cells, there rarely being 
 any lumen whatever (Fig. 7(3). All grades may exist between this 
 form and that previously described. Two main varieties of the 
 solid-celled carcinoma are recognized, dej)ending upon the amount 
 of stroma present: when this is excessive, the tumor is said to be a 
 "scirrhus" (srlrrlums carclnoina); when the stroma is deficient, and 
 the cellular elements conspicuous, it is called a medullary carcinoma, 
 
126 
 
 TUMORS 
 
 or, from its gross resemblance to the brain on cross-section, "encepha- 
 loid." When stroma and parenchyma are present in equal amount 
 it is described as carcinoma simplex, or "acute scirrhus." Solid-celled 
 carcinoma affects especially the mammary gland and the cervix uteri, 
 though in both situations various combinations of carcinomatous 
 growth may be encountered. 
 
 Fig. 76. — Microscopic appearance of solid-celled carcinoma, arising in the neck of 
 the uterus. (From "Diseases of Women," Bland-Sutton and Giles.) 
 
 Gland carcinoma is especially prone to ulceration, the ulcer being 
 deeper than in epithelioma, and there being a much greater tendency 
 to fungosity. Colloid degeneration is not unusual, particularly in 
 carcinomas of the intestinal tract; it is due, according to Adami, to 
 the accumulation within the cells of modified mucin which they 
 cannot excrete, the result being that entire alveoli may be distended 
 with this glistening, translucent material. 
 
 Symptonts. — The symptoms of gland carcinoma depend so much 
 upon the seat of the tumor, that their description is best postponed 
 to the chapters on regional surgery. 
 
 Prognosis. — Untreated, or treated only palliati^'ely, the expectation 
 of life in carcinoma has been estimated at eighteen months for the 
 medullary, and two and one-half years for the scirrhous variety; for, 
 although, in the latter, many patients survive three, five, or even ten 
 years, yet an equal number die in less than the average period, men- 
 tioned. The prognosis after operation will be discussed with regional 
 surgery. 
 
TRANSITIONAL LE PI DO MAS 127 
 
 Treatment. — All operable carcinomas should he excised, at the 
 earliest possible moment, in one mass with the neighboring lymph 
 nodes; when iMoperal)le, palliative treatment consists in dressing the 
 ulcer (of external cancers) with permanganate of potash or other 
 deodorant, and in giving such stimulants, tonics, and anodynes as 
 shall make life endurable. Certain palliative operations are applicable 
 to inoperable internal carcinomas. 
 
 Transitional Lepidic Tumors. Mesothelioma and Endothelioma. — 
 In addition to the classes of lepidomas already described (derived 
 from epiblast and hypoblast), Adami places in a separate division 
 those tumors derived from mesothelium and endothelium. As these 
 were themselves derived from the mesoblast, and as this in turn was 
 formed partly by epiblast and largely by hypoblast, it is but natural 
 to find that mesothelial and endothelial tumors present at times the 
 characters of lei)idomas (epi-or hypoblast), at others those of hylomas 
 (mesoblast). Therefore they are well named transitional lepidomas, 
 because while they usually resemble ordinary lepidomas, they at 
 times in whole or in certain parts grade so imperceptibly into hylomas 
 that it is impossible to say to which class they really belong. In 
 this group, embryogenetically at least, belong the lepidic tumors of 
 the uterus; as these closely resemble similar tumors of epiblastic 
 (mammary) and hypoblastic (intestinal) origin, Adami supposes that 
 the epiblast has overgrown the primary mesoblast of the genital tract. 
 These tumors, however, frequently appear either sarcomatous {i. e., 
 mesotheliomatous) or endotheliomatous in parts, so it is evident that 
 they possess primary mesoblastic characteristics. While there are 
 typical transitional lepidomas (adenoma), the tumors in this group 
 most important for the surgeon are atypical (carcinomatous) in 
 nature. Adenoma and carcinoma of the prostate are included in this 
 class, as well as rarer tumors of the ureters, seminal vesicles, and vas 
 deferens; similar growths of adrenal, kidney, ovary, and uterus; also 
 mesothelioma of the pleura, etc. For reasons already given, the 
 tumors of the uterus resemble usually ordinary gland carcinoma. The 
 most important surgically of all the mesotheliomas is the malignant 
 growth of the adrenal gland known as hypernephroma. 
 
 Hypernephroma. — The medulla of the adrenal develops from the 
 nervous system, and its cortex from the mesothelium, closely related to 
 that which forms the cortex of the kidney. The adrenal medulla sel- 
 dom gives origin to a tumor; when it does it forms a ganglioneuroma. 
 The hypernephroma (alveolar sarcoma, angeiosarcoma, perithelioma, 
 carcinoma, etc.) springs from the adrenal cortex, and is, therefore, 
 classed as a mesothelioma. In it may be clearly seen the transitional 
 type from carcinomatous (lepidic) to sarcomatous (hylic) arrange- 
 ment of the alveoli (Fig. 77). Owing to fetal inclusions in ovary or 
 testis, mesotheliomas may occur also in those organs, and more rarely 
 in the kidney itself (Chapter XXV). The ordinary hypernephroma 
 behaves as a malignant tumor, growing sometimes to immense size, 
 invading the kidney, and possessing firm retroperitoneal connections. 
 
128 
 
 TUMORS 
 
 The only treatment is prompt excision, which implies nephrectomy; 
 the operation is difficult and bloody, and recurrence is usual. Bony 
 metastases occur, occasionally only a single metastasis (Scudder, 1910). 
 
 nbnzi 
 
 nbnzi: 
 
 Fig. 77. — Hypernephroma of kidney. Transition from adenomatous to sarcomatous 
 type of growth: nbnz', adenomatous overgrowth of solid columns or masses of cells 
 of adrenal type; nhm", transition to sarcomatous arrangement; K, a kidney tubule 
 
 involved in the growth. (Debernardi.) 
 
 Mesothelioma. — Mesothelioma may arise in pleura, peritoneum, or 
 rarely in pericardium or synovial membrane. It appears as a pseudo- 
 inflammatory thickening of the serous membrane, producing a 
 flattened, nodular or fungous tumor, composed of "elongated acini, 
 lined with irregular, swollen cells, . . . resembling the curiously 
 epithelioid type of cells we encounter in some endotheliomas," these 
 acini lying in an abundant fibrous stroma (Adami). I have seen one 
 mesothelioma of the pleura, in a child of three years, not recognized 
 as such by the surgeon, who operated for empyema. 
 
 Endothelioma. — From this class should be excluded blood and lymph 
 vascular changes not truly blastomatous. All such conditions as 
 nevi, telangiectases, etc., will be discussed under surgery of the vascular 
 system (p. 244). Here we have to do only with typical and atypical 
 neoplasms of endothelial tissues. They are classed as hemangeio- 
 endothelioma and lymphangeio-endothelioma ; surgically they are not 
 of much interest. Briefly, they are formed by concentric, and at times 
 eccentric proliferation of endothelium of blood or lymph capillaries. 
 An atypical hemangeio-endothelioma of the inner surface of the 
 cranial dura mater, in which calcareous deposits have occurred, is 
 called a psammoma. Perithelioma is a tumor in which the lymph cells 
 lining the perivascular lymph spaces proliferate; when hyaline degen- 
 eration occurs in these cells, the tumor is called a ci/lindroma. The 
 growth occurs in the kidney, bones, and skin. Endothelioma occurs 
 oftenest in the skin, in the region of the parotid, in the genital glands, 
 bones, lymph nodes, and dura (Park, 1907). 
 
 Tumors of the Carotid Body (p. 680) tend to the peritheliomatous 
 type. 
 
CYSTS 129 
 
 Melanoma.- Tliere is great uiiccrtainty wiR'tlicr tliis tumor belongs 
 among sarcomas or not. Adami is inclined to place it among transi- 
 tional Icjjidomas. It arises by atypical i)r()lifcration of tlic pigment- 
 containing cells {rliroiiKttophorcs) of the rete Maipigliii in tlu; skin, 
 or of similar cells in the uveal tract of the eye. Ordinary pigmented 
 nevi, which are either congenital deformities, or typical as distin- 
 guished from aiy])i('(d melanomas, sometimes become transformed 
 in adult life into this most malignant type of tumor. Bcgimiing in 
 a cutaneous nevus or in the eye, a melanoma gives rapid and wonder- 
 fully widespread metastasis, by both blood and lymph chamicls, to 
 skin, internal organs (especially liver), ])ones, lungs, brain, etc. The 
 only ircdiincnt is wide excision or amputation before metastasis occurs. 
 
 Cholesteatoma. — Cholesteatoma is a tumor regarded l)y 15orst and 
 others as of endothelial origin; others (Ziegler) think it ectodermic, 
 resembling ordinary dermoid cysts (p. 130). The contents consist 
 of "white, pearl-like, glistening masses, which are concentrically 
 arranged," apparently the remains of compressed and cornified 
 epithelial cells. They occur in the middle ear, pia mater, and urethra. 
 The}' vary in size from a cherry seed to a hen's egg. They may cause 
 pressure symptoms in the cranium, or otitis media when in the middle 
 ear (Lexer). Excision is the best treatment. 
 
 CYSTS. 
 
 A cyst is an abnormal but encapsulated collection of fluid, in a 
 cavity which is not provided with any outlet. The fluidity of the 
 contents varies from liquid to semi-solid. One cavity (unilocular) 
 or many (multilocular) may exist. A cyst is to be distinguished from 
 an abscess, which is not strictly encapsulated; from dilatations (ectasia) 
 of normal channels (varix, aneurysm) which still have an outlet; from 
 effusions or transudations into preformed and normal cavities, which 
 are classed apart (hydrops articuli, hydrocele, hygroma, hydrothorax, 
 hydrocephalus, etc.) — though such collections may be encysted; and 
 from cystomas, which is a term sometimes used to describe neoplasms 
 in which cysts form incidentally (p. 119); but a distinction cannot 
 always be made clinically between cysts and cystomas. 
 
 Cysts may be classed as Extravasation, Retention, and Parasitic 
 Cysts. All cysts tend to become spherical or oval unless compressed 
 by neighboring parts. 
 
 Extravasation Cysts. — These are encapsulated collections of fluid 
 not in a preexisting cavity. An example is the hematoma, due to 
 extravasation of blood, which as the result of reaction and condensa- 
 tion in the surrounding structures, becomes in time encapsulated. 
 Certain bursal tumors (p. 281) may belong in this class. Extravasa- 
 tion of lymph, forming a chylous cyst, is very rare (p. 268). Extra- 
 vasation of urine rarely forms a distinct cyst. 
 
 Retention Cysts. — Retention cysts arise in preexisting cavities. 
 They form the largest and most important class, and may arise either 
 9 
 
130 
 
 TUMORS 
 
 because there is no opening to the cavity, or because the normal 
 opening is obstructed. In either case it is evident that secretion or 
 transudation into the cyst must be more rapid than absorption. 
 Generally speaking, these cysts may be classed as post-natal or 
 antenatal in origin. 
 
 I. Of Post-natal Origin. — Examples of cysts due to obstruction of 
 ducts are Raiuila, Cysfs of Bartholin's Gland, Galadocele, Sebaceous 
 Cysts, Hydronephrosis, Hydrops Vesicce Fellece, etc. Examples of cysts 
 formed in cavities normally having no outlet are corpora lutea and 
 iollicular cysts of the ovary, cystic goitre, etc. 
 
 Fig. 78. — Sequestration cyst, or dermoid (congenital at:)normality) of 
 scrotal raphe. Episcopal Hospital. 
 
 Sequestration Cysts deserve separate mention. They are due to 
 the sequestration and detachment of portions of the true skin either 
 (1) during ante-natal development, when they are congenital, and 
 occur along the fissural lines of the body; or (2) are caused in post- 
 natal life by implantation of portions of the true skin by trauma. 
 Most dermoids belong to the former class (Fig. 78), though some, 
 especially pilo-nidal cysts, are occasionally of post-natal development. 
 Implantation dermoids are seen in the fingers of sewing women, or 
 in the faces of shavers. I have several times excised from the face 
 cysts supposed to be wens, which on opening were found to contain 
 two or three long hairs growing from the interior of the c yst wall, 
 which in such cases is lined with squamous epithelium, not with 
 secreting cells. 
 
 II. Of Ante-natal Origin. — These may be considered in three 
 divisions : 
 
 1. Cysts Due to Persistence of Parts of Embryonic Ducts. — Thyro- 
 glossal, Branchial, Vitello-intestinal, and Urachal Cysts: the 
 "Tubular Cvsts" of Bland-Sutton. 
 
GENERAL REMARKS ON EXCISION OF TUMORS 131 
 
 2. Cysts of Geniio-urinary Passages: 
 
 (a) In the Male. — Encysted liydrocele of testis, probably due to per- 
 sistence of the cmbrj'onic vasa ett'erentia. 
 
 (6) In the Female. — From various tubules composing the parova- 
 rium, and perhaps from the paroophoron. 
 
 3. Congenital Cysts of Glandular Organs. — The liver and kidney 
 are especially affected. The pathology is obscure. 
 
 Parasitic Cysts. — In man, two main varieties of parasitic cysts 
 are found, those due to Trichina Spiralis and Tenia Echinococcus. 
 The trichina, much rarer, forms very small cysts, oftenest in muscles 
 (p. 27()). The echinococcus, commonly known as hydatid cysts, may 
 attain an immense size. This parasite is an inhabitant of the intes- 
 tinal tract of dogs, and the ova may gain entrance to the digestive 
 tracts of those who have to do with dogs and whose habits are not 
 very cleanly. It is a rather rare disease in this country. The shell of 
 the ovum is dissolved by the patient's intestinal juice, and the larva, 
 thus liberated, works its way through the intestinal mucosa usually 
 into a branch of the portal vein, and thus reaches the liver; here it 
 proliferates, and one large, or innumerable small, conglomerate cyst 
 will be found depending upon the stage of development. They are 
 easily recognized by the "booklets" they contain. The lungs, brain, 
 and other parts of the body may also be affected. Treatment is 
 discussed in Chapter XXIV. 
 
 Fig. 79. Elliptical incision for the Fig. 80. — Double S<S incision for the 
 
 removal of a tumor. removal of a tumor. 
 
 GENERAL REMARKS ON EXCISION OF TUMORS. 
 
 The incision should correspond with the natural folds of the part; 
 no skin need be removed in excising benign growths unless very large, 
 when the redundancy may be removed with the tumor by an elliptical 
 incision or one in the form of double SS (Figs. 79 and 80) . If a tumor is 
 very large, it is not wise to make the entire incision at once, as bleeding 
 is more easily controlled by working down to the main blood-supply 
 through a small incision, and completing this when the main vessels 
 
132 TUMORS 
 
 have been ligated. IMost external (i. e., not visceral) tumors are exposed 
 on dividing the skin and superficial fascia; if beneath the deep fascia 
 they should be approached through the proper muscular interspace. 
 A tumor which is encapsulated usually may be enucleated, keeping 
 the scalpel close to the capsule. Malignant tumors necessitate the 
 removal of healthy tissues on all sides, and usually of the overlying 
 skin ; as they frequently extend along and surround large bloodvessels, 
 careful dissection is required. Cancers should not be removed by 
 blunt dissection: the bruising of the tissues this entails causes egress 
 of malignant cells into the surrounding tissues. A malignant tumor 
 never should be cut into in the process of removal; to do this may 
 infect the entire wound with cancer cells, and may cause alarming 
 hemorrhage from the tumor itself which it will be very difficult to 
 control. If a tumor when exposed is found to be so placed that it 
 cannot be removed with safety, the operation must be abandoned; 
 in some cases the pedicle of the tumor may be secured, and the main 
 bulk cut away; or the main vessels may be ligated, to starve the 
 growth (p. 655). In gastric and intestinal tumors a palliative opera- 
 tion is frequently possible. 
 
 If a tumor, before operation, is clearly inoperable, of course no 
 attempt should be made to remove it. Inoperability may depend 
 on general conditions (the cachectic state of the patient, and 
 probability or certainty of metastases which will kill the patient 
 within the appointed time even if the primary growth were removed), 
 or on the local condition ; fixity of the growth, especially in the neigh- 
 borhood of great vessels is always a sign to be seriously considered. 
 It is important for the surgeon to have a clear understanding with his 
 patient as to the extent of the operation possible and permissible. 
 While often invading and obliterating veins, carcinoma generally 
 respects arteries, even when entirely surrounding them (Crile) ; so that 
 it is usually possible to dissect the artery free. E\'erything but life 
 may be disregarded in operating for malignant growths: thus it is 
 entirely justifiable to amputate the thigh, if a tumor is so placed as 
 to necessitate excision of the popliteal artery, w^hich would surely 
 cause gangrene; it is proper to excise muscles, tendons, bones, veins, 
 arteries and even nerves, when, as in the neck, to do so will bring the 
 operation to a successful conclusion without jeopardizing life. A 
 patient will not miss one pneumogastric nerve or one carotid artery, 
 and as a rule he will prefer to live without a clavicle and Avith a power- 
 less arm than to keep his tiunor and die. In some tumors resection 
 of the thoracic or abdominal wall is necessarj^; the greater part of the 
 stomach may have to be removed in one piece with the transverse 
 colon, or the descending duodenum eji masse with the head of the 
 pancreas. 
 
CHAPTER V 
 
 SURGICAL TECHNIQUE. 
 
 There are readily available so many excellent works on Band- 
 aging, Antiseptic and Aseptic Tecliniqne, Minor Surgery, Anesthetics, 
 etc., that in the present chapter little will be attempted beyond 
 discussing briefly the principles underlying these procedures. 
 
 BANDAGING. 
 
 Bandages are employed to hold dressings in contact with a wound, 
 to maintain splints in position, or simply to support the part. Those 
 most generally useful are made of unbleached muslin, which may be 
 torn into any width. For the fingers a bandage should be one inch 
 in width; for the head and neck, two inches; for the forearm, two 
 inches and a half; for the arm and leg, three inches; for the thigh and 
 shoulder, three inches and a half; and for the trunk, four inches wide. 
 The length varies with the part to be bandaged and with the purpose 
 for which the bandage is employed: the finger bandages are usually 
 one or two, and the larger from seven to nine yards in length. When 
 prepared for use a bandage is rolled tightly into the form of a cylin- 
 der (roller bandage), the free end being known as the initial extremity. 
 To roll a bandage by hand, fold one end on itself for about six inches; 
 again fold it in half, thus making four thicknesses of three inches each ; 
 again fold it in half, making eight thicknesses an inch and a half long; 
 and keep folding the bandage on itself until a solid core is formed. 
 This core is then held in the left hand, between the thumb and first 
 two fingers, and the free end is firmly but tightly grasped in the web 
 of the right thumb (Fig. 81); then by alternately supinating and 
 pronating the left hand, rotating the roller in supination but relaxing 
 the grip on it during pronation, the free end of the bandage is guided 
 on to the roller, which increases in size at each turn of the hand. 
 The right hand should keep the bandage taut, so as to make the 
 roller as firm as possible. A mechanical bandage winder is useful in 
 hospitals or wherever many bandages are to be rolled. 
 
 In applying a bandage, the initial extremity is placed on the part, 
 and the roller carried around the limb transversely from left to right, 
 once or twice, to fix the bandage. As the bandage gradually covers 
 the part, each turn should be so applied as to overlie that just below 
 by one-third or more of its width ; when it is found impossible to make 
 the bandage lie flat on the limb, owing to the conical shape of the latter, 
 the roller is to be carried off obliquely, the bandage fixed on the limb 
 
134 
 
 SURGICAL TECHNIQUE 
 
 by the thumb or finger of the left hand, and the bandage reversed 
 (Fig. 82). If the limb is conical it may l)e necessary to apply the 
 initial extremity of the bandage obliquely in order to fix it without 
 making a reverse. When the part has been completely covered in, 
 the end of the bandage may be fastened with a pin applied trans- 
 versely to the end of the roller; or strips of adhesive plaster may be 
 used instead. The point of the pin should always point downward 
 toward the distal extremity of the limb. 
 
 Fig. 81. — Rolling a bandage by hand. 
 (Wharton.) 
 
 Fig. 82. — Method of making reverses. 
 (Wharton.) 
 
 Fig. 83. — Method of removing a bandage. (Wharton.) 
 
 In removing a bandage, nothing is so clumsy and time consuming 
 as to drag the end around and around the limb as a long streamer. 
 The entire bandage should be bunched up and passed from hand to 
 
BANDAGING 
 
 135 
 
 hand as it is unwound (I'l^- 83). If soiled, it. may be removed by band- 
 age scissors (Fig. 84), the blunt end easily slii)]jiiig between the folds 
 of bandage, (^are should l)e taken not to cut over a subcutaneous 
 bone (e. g., the shin), and always to keep the blades at right angles to 
 the surface of the limb, for fear of ]))nehing u}) the skin between them. 
 As a general rule, bandaging- should always begin below and i)roceed 
 toward the trunk, and a bandage should not be api)lied to a limb 
 without co\'ering in the entire limb from fingers or toes uj) to and 
 beyond the diseased part. In limbs slightly diseased, swelling of the 
 distal part may not always follow the careful a])pIication of a bandage 
 to the afi'ected i)art alone, but usually the whole limb is more or less 
 inflamed, and constricting it at the seat of greatest swelling may 
 produce marked edema of the distal part if unsupported by the band- 
 age, and cause great discomfort to the })atient. Tender no circum- 
 stances should a bandage })e ai)plied so tightly as to interfere with 
 the circulation. Hippocrates taught, and it is still absolutely true, 
 that where it is desired to give pressure to a part by means of bandages, 
 it is much safer to secure this by employing several superimposed 
 bandages than to draw the primary bandage unduly tight. 
 
 Fig. 84. — Bandage scissors. 
 
 Gauze bandages are much emploj'ed at present; but they are inferior 
 to muslin bandages except for holding dressings lightly in place; 
 they are of most use for the head and neck, because they are so 
 elastic that it is rarely necessary to make reverses. But if drawn at 
 all firmly they pull into strings and are more liable than muslin to 
 cause injurious constriction. 
 
 Flannel bandages are of much value for support in cases of edema, 
 varicose veins, etc. They are elastic, especially when cut on the bias, 
 and are less apt to irritate the skin than muslin or gauze. Bandages 
 of elastic webbing are used for the same purposes. 
 
 Varieties of Bandages. — The bandages most frequently employed 
 are the spiral or spiral reversed (Fig. 82), which is universally used 
 in the extremities; the recurrent (Fig. 85), used for stumps, the head, 
 etc.; the spica (Fig. 86), which is employed to cover the shoulder, 
 groin, buttock, etc.; figure-of-eight bandages (Figs. 87, 88 and 89), used 
 to cover joints, to draw the shoulders backward or forward, etc.; 
 T-bandages (Fig. 90), for holding dressings to the perineum; the 
 many-tailed bandage, or bandage of Scultetus (1655) (Figs. 91 and 92), 
 especially useful for abdominal wounds or other cases where the 
 
136 
 
 SURGICAL TECHNIQUE 
 
 patient cannot be supported while a roller banday-e is applied. The 
 application of these various bandages is sulliciently indicated in the 
 accompanying figures: 
 
 f^/f ,//'/'/ !:',^'^m/Ii. 
 
 I'// 'I ' , -- 
 
 Fig. 85. — Recurrent bandage. 
 (Wharton.) 
 
 Fig. 80. — Ascending spica" bandage. 
 (Wharton.) 
 
 Fig. 87. — Figure-of-eight bandage of the Fig. 88.— Figure-of-eight bandage of 
 
 knee. (Wharton.) the neck and axilla. (Wharton.) 
 
 Fig. 89.— Posterior figure-of-eight bandage of the chest'. (Wharton.) 
 
HAND AGING 
 
 137 
 
 Fixed Dressings. This is a term used for l)iiii(lii<,^('s into the meshes 
 of which some sul)stauee lias been incorporated which on drying 
 becomes stiff. The materials usu- 
 ally emj)l()yed are starch, silicate of 
 sodium, or i)laster of Paris, espe- 
 cially the last. The bandage itself 
 is made of crinoline or coarse 
 meshed gauze. 
 
 Plaster of Paris.-Tliis powder is 
 hygrosco])ic; when moistened and 
 allowed to dry it is converted into 
 gypsum, the process })cing known 
 as scU'uuj. It is worked into the 
 meshes of the bandage by a spatula; 
 the bandage is then loosely rolled, 
 tied in waxed paper, and put away 
 in an air-tight box until wanted. 
 These bandages may be kept thus 
 for several weeks, but are always 
 better when freshly made. When 
 it is desired to use them, one band- 
 age is placed on end in hot water 
 which completely covers it, and is 
 until bubbles cease to rise. 
 
 Fig. 90. — Double tailed, or T-handage. 
 
 allow'ed to remain in the water 
 The bandage is then removed from the 
 
 Fig. 91. — Bandage of Scultetus (many tailed). 
 
 Fig. 92. — Scultetus bandage applied; overlapping turns fastened with safety- 
 pins. Episcopal Hospital. 
 
 water, is grasped by its two ends in the hands, and is squeezed as dry 
 as possible. It is then applied as an ordinary roller bandage to the 
 
138 
 
 SURGICAL TECHNIQUE 
 
 part (Fig. 93), which must have been previously protected by one or 
 two layers of flannel bandage or of cotton batting; bony ])rominences 
 should be additionally protected by raw cotton or felt pads. A suffi- 
 cient number of ])laster bandages should be applied to render the 
 
 Fig. 93. — Plaster-of-Paris bandage being applied to leg. The foot should be 
 kept at a right angle with the leg. Orthopsedic Ho.spital. 
 
 bandage firm when it has set. Usuall}' four to six are required for the 
 foot and leg, eight to ten for the knee, and twelve or more for the pelvis 
 or trunk. The bandages should be placed in the water only as needed ; 
 they set quickly, and prompt action and skilful work are required to 
 make a satisfactory gypsum case, or "cast" as it is popularly called. 
 
 Fig. 94. — Removing gypsum case by means of Hunter's saw. Orthoi aedic Hospital. 
 
 Before the last bandage is applied, the projecting margins of the 
 underlying flannel bandage may be turned down over the ends of the 
 cast, and be held in place by a few turns of the last bandage : this covers 
 in the rough edges of the cast, which unless co^'ered cause great 
 
ANTISEPSIS AND ASEPSIS 
 
 139 
 
 annoyance to tlie patient. Finally some "plaster eream" may be rul)bed 
 all over the .surface of the last handaj^a-: tiiis is made hy adding just 
 enough water to a couple of handfuls of plaster to make a thick paste. 
 This refinement not only improves the appearance of the cast, hut hy 
 giving it a glazed surface (enhanced by wiping with gauze moistened 
 in alcohol) keeps the cast clean much longer, "^riie gyj)sum usually 
 is (juite firm enough in half an hour for the i)atient to be mo\ed easil}'. 
 Starch.^ — Starch is applied in the form of a paste, by rubbing it into 
 the bandages as they are applied. It is much more brittle and liable 
 to break than gypsum, but may be used as a top dressing to a soiled 
 cast which it is undesirable to remove. 
 
 Fig. 95. — Gj^psum dressing trapped. Orthopaedic Hospital. 
 
 Silicate of Sodium. — Silicate of sodium is a pale yellow liquid of the 
 consistency of mucilage. It is best applied to the bandages by rolling 
 them on a winch in a trough full of the liquid, as in the apparatus of 
 G. G. Davis. Silicate makes a light, ornamental cast, possessing all 
 the good qualities of the gypsum, except that at least thirty-six hours 
 are required for it to harden completely. It is much cleaner than 
 plaster of Paris and is readily soluble in water. 
 
 These fixed dressings are best removed, I think, by the use of 
 Hunter's saw^ (Fig. 94); when the gypsum is cut to the underlying 
 bandage, a fact easily detected by the sensation imparted to the hand 
 by the saw, the remaining bandages, and any part of the cast too 
 soft to be cut by the saw, may be cut by a stout pair of bandage 
 scissors. When desirable, a cast so removed may be sprung oflf and 
 reapplied, being held together by adhesive straps or bandages. The 
 gypsum may be cut away at any time (most easily while still setting) 
 to make a "window" or "trap" through which a wound may be 
 dressed (Fig. 95). 
 
 ANTISEPSIS AND ASEPSIS. 
 
 In order to prevent entrance of microorganisms into wounds at 
 operation or other times, it is absolutely necessary to take such pre- 
 cautions as will kill all bacteria which might be introduced through 
 the medium of instruments, dressings, or the hands of surgeons, 
 assistants, or nurses; or from the skin of the patient himself, or 
 from septic structures within his body invaded during the course of 
 
140 SURGICAL TECHNIQUE 
 
 operation. A thing is sterile when there are no bacteria on it, or when 
 all the bacteria on it are dead. Everything that has not been sterilized 
 is considered in surgery to he seidic. It is next to impossil)le to remove 
 bacteria, and entirely impossible to know clinically whether all the 
 bacteria have been removed or not. The only recourse, therefore, 
 is to kill them all. This is most readily accomplished by the use of 
 moist heat (boiling), as no bacteria can survive a temperature of over 
 100° C. for more than ten to fifteen minutes. Everything that can be 
 boiled may therefore be sterilized in this way, and must not again 
 be touched by anything septic; if it is, it must be re-sterilized before 
 it can be used safely. Instruments, basins, buckets, etc., are readily 
 sterilized by boiling. Enough sodium carbonate (washing soda) 
 should be placed in the water to prevent oxidation (rusting) of the 
 instruments (tablespoonful to a quart). Dressings may be treated 
 in the same way, but as they take much longer than instruments to 
 cool off, and are nearly useless when wet, it is much more satisfactory 
 to sterilize such things in a steam autoclave. For this purpose they 
 are loosely wrapped in an outer covering, which is undone after they 
 have been sterilized, and the contents of the package are removed 
 only by sterile hands or instruments at the time of operation. If 
 carefully wrapped and kept so, such dressings may be preserved in a 
 sterile state for several days at a time; though it is always safer to 
 re-sterilize them on the day of the operation. As the temper of knives 
 is readily spoiled by boiling, and as their surfaces are smooth and 
 therefore readily cleansed mechanically, I think it is best to use 
 chemicals to sterilize them; placing them for twenty minutes in hot^ 
 carbolic acid solution (5 per cent.) and then in alcohol (70 per cent.) 
 until used. 
 
 The hands of the surgeon and his assistants, and the skin of the 
 patient, however, cannot be sterilized by heat; they must be prepared 
 by mechanical and chemical processes. (When a surgeon speaks of 
 his hands, he should use the term in the sense of the Greek word '/J^l>, 
 which meant the hands and forearms up to and including the elbows.) 
 The hands are best prepared by washing in hot soapsuds, with careful 
 use of a nail-brush, for ten minutes; then the soap is rinsed off, and 
 further removed by soaking the hands and forearms in alcohol; finally 
 they are soaked in a hot solution of bichloride of mercury (1 to 2000) 
 or of carbolic acid (2.5 per cent.). The patient's skin is prepared in 
 the same way, and is covered with sterile gauze until the time of 
 operation. The mechanical cleansing with the nail-brush, aided by the 
 macerating efi'ect of heat, and soapsuds, removes all loose epithelium 
 and probably removes almost all the germs present. The alcohol 
 by its dehydrating effects opens up the orifices of the cutaneous glands 
 and allows the antiseptic subsequently used to penetrate the skin 
 more effectively, thus weakening, if not killing, the germs always 
 present in the deeper layers. IVIost surgeons in this country prefer to 
 
 1 It is worth noting in this place that all antiseptic solutions are much more 
 efficient when hot than if cold or merely luke-warm. 
 
AX T J SEPSIS AND ASEI'SIS 141 
 
 wear ()\tT tlit'ir hands tliiii ruhhcr gloves wliicli have been properly 
 sterili/.fd. Tliere is no douht to my iiiiiid that they are a most val- 
 uable addition to the surj^ical armamentarium, chiefly as a jirotection 
 to the sur<:;et)n from contamination in septic cases. The use of fi;love.s 
 in no way absolves the surj>;eon from careful ])rei)aration of his hands, 
 l)ut it enables him in emeru'cncy to pass from a septic tt) an aseptic 
 oi)eration with an imi)unity which can never be enjoyed when he 
 operates with bare hands. All ])ersons concerned in the operation 
 wear sterile gowns, and caps, and the operators wear face masks of 
 gauze to ])revent contamination of the wound or the instruments or 
 dressings in any concei\"able manner. 
 
 lodin Disinfection. — (irossich in 1908 found if the patient's skin 
 (without previous preparation except dry shaving) were painted with 
 a 10 to 12 per cent, alcoholic solution of iodin shortly before operation, 
 at the time of operation, and at the close of the operation, the woimds 
 healed better than after the habitual methods of skin prej)aration. 
 This method is poi)ular for its simplicity and efficiency, and is now in 
 general use. ]\Iost surgeons find an alcoholic solution of from 3 to 5 
 per cent, strong enough, but many do not sufficiently appreciate the 
 fact that the skin must be dry, if the iodin is to be of any use. It 
 must not have l)een wet for three or four hours at least. 
 
 Antiseptic methods of operating wTre introduced before aseptic 
 methods (Lister, 18G5; Lucas-Championniere, 1869, 1876), and are 
 still most widely applicable. Here, after preparing the dressings, 
 instruments, and skin as above, the surgeon keeps his instruments in 
 antiseptic solutions (2.5 per cent, carbolic acid); uses sponges soaked 
 in antiseptics for mopping out the wound; and at the conclusion of 
 the operation applies a stronger antiseptic solution (5 per cent, carbolic 
 acid, 5 or 10 per cent, zinc chloride, 1 to 1000 corrosive sublimate, etc.) 
 to the entire surface of the wound. In this way he makes sure that 
 any microorganisms introduced into the w^ound, accidentally, will 
 have an unfavorable soil for growth, and that in all probability they 
 will be so weakened by the antiseptics employed as easily to be killed 
 by the tissues of the body. This method of operating is applicable 
 to all primarily septic conditions (compound fractures, necrosis, 
 abscesses, malignant tumors, most amputations, etc.), and is valuable 
 in a somewhat modified form in all operations where the tissues are 
 much })ruised or long exposed to the atmosphere during the course 
 of the operation (some excisions, ununited fractures, tedious dissec- 
 tions, etc.). When, however, the operation is of short duration (under 
 half an hour), or when the tissues, even during a longer operation, 
 are not bruised or otherwise unduly injured, and especially in visceral 
 surgery, the aseptic method is superior. 
 
 Aseptic methods of operation have been in general use only for the 
 last ten or fifteen years, and were systematized largely by Terrier and 
 his pupils. The instruments, dressings, etc., are sterilized, and the 
 instruments are placed in sterile water or laid on a table covered with 
 sterile sheets. The hands and the patient's skin are prepared in the 
 
142 SURGICAL TECHNIQUE 
 
 usual way, but no antiseptics whatever are used during the course of 
 the operation; everything coming into contact with the wound is 
 sterile; and it depends on the unceasing and seemingly pedantic pre- 
 cautions of the surgeon to keej) the wound aseptic. If one mis-step 
 is made, the aseptic has to be abandoned for the antiseptic method; 
 and while I think the surgeon should always employ the aseptic method 
 when he safely can, because antiseptics are at times harmful to the 
 patient, and occasionally delay the process of repair, yet it cannot be 
 denied that adherence to a strictly aseptic technique is much more 
 difficult; and it must be acknowledged that many surgeons seem incap- 
 able of practising it thoroughly. When either method is properly 
 employed, the wound heals without noticeable inflammatory reaction, 
 no stitch abscesses form, no discharging sinuses remain, no ligatures 
 are slowly eliminated from its depths, no granulations persist at one 
 end of the incision, the comfort of the patient is enhanced, and the 
 after-treatment much simplified. 
 
 MINOR SURGERY. 
 
 Counter-irritation. — Counter-irritation is conveniently secured by 
 the use of very hot compresses, by turpentine stupes, or by means 
 of plasters of mustard, capsicum, etc. While these remedies are 
 merely rubefacient in their effect, cantharides plaster will produce a 
 blister (vesication); the surface of the plaster should be wiped with 
 olive oil or petrolatum, so as to prevent it sticking to the cuticle. 
 It should be removed in six or eight hours, and the blister will com- 
 monly draw for several hours more; meanwhile it should be dressed 
 lightly with an ointment, and when fully drawn the tense cuticle 
 should be punctured with an aseptic bistoury, and allowed to collapse 
 on to the face of the blister as the serum exudes. When the blister 
 shows a tendency to dry up, this may be encouraged by applying talc 
 or other dusting powder. Canterization is readily secured by means 
 of the Paquelin cautery, in which the platinum cautery point is first 
 brought to a red heat in an alcohol flame, and is then kept incandescent 
 by exposing it to the vapor of benzole or rhigolene, which is pumped 
 along the hollow handle of the cautery iron, from the receptacle w^here 
 it is contained, by means of a hand bulb. To produce vesication or 
 still slighter degrees of counter-irritation, it is sufficient merely to 
 touch the skin with the cautery iron when at a cherry red heat, or 
 even to hold it close to the skin without bringing the iron into actual 
 contact w^ith it. In certain operations the actual cautery is of the 
 utmost value in checking the oozing of blood or destroying the fungous 
 granulations of inoperable tumors. The wound left is rendered aseptic 
 by the heat, and will usually heal without suppuration. Whenever 
 using the actual cautery, the highly inflammable quality of ether must 
 be remembered. 
 
 Acupuncture. — Acupuncture is a little operation sometimes used 
 in cases of lumbago, etc. After preparing the patient's skin as for an 
 
MINOR SURGERY 143 
 
 operation, six to ten sterile needles (ordinary hat pins will do) are 
 tlirust intt) the k)ins with a quiek })oring motion, and are allowed to 
 remain in i)laee a few minntes. Care, of course, must be exercised not 
 to injure any superficial vein, nerve, etc., and not to enter the spinal 
 canal. No anesthetic is required. 
 
 Vaccination. — Vaccination, though usually done by the family 
 I)hysi(i;in, is a surgical procedure. The method I prefer is the follow- 
 ing :'the skin of the arm is rubbed briskly with an alcohol sponge, and 
 vigorously dried with sterile gauze; this arouses the circulation of the 
 part, and makes the virus more apt to " take." Then with the belly of 
 an asej)tic and rather dull scalpel the cuticle is scraped ofl' over an area 
 about s inch (1 cm.) square until the surface is moist. No blood should 
 be drawn. The vaccine is then quickly applied, and rubbed into the 
 abraded area by means of the ivory point or glass tube in which it is 
 supplied. The vaccinated area is allowed to dry, conqjletely , in the 
 air, and no shield or bandage is em])loyed. In a continuous series of 
 several hundred vaccinations by this method, when house surgeon 
 at the Episcopal Hospital, I failed to secure a "take" at the first 
 attempt, in only two or three previously un^■accinated patients. The 
 wound should be painted daily with a 8 per cent, solution of iodin. 
 
 Hypodermic Injections. — Convenient tablets containing the requi- 
 site amount of the drug are easily obtained from manufacturers. 
 The tablet is dissolved in a half dram of sterile water or saline solu- 
 tion, or the water with the tal)let in it may be sterilized in a spoon 
 over a flame. The fluid is then drawn up into the barrel of the hypo- 
 dermic syringe previously sterilized by boiling or by soaking in an 
 antiseptic solution (which should of course have been removed by 
 rinsing the interior of the syringe in sterile water). The sterilized 
 hollow needle is then screwed on to the nozzle of the syringe, and 
 any bubbles of air are expelled by driving the piston home, while the 
 needle is held upward, until the fluid spurts. Then a fold of the 
 patient's skin, prepared by vigorous rubbing with an alcohol sponge, 
 is picked up between the thumb and finger of the left hand, and the 
 needle quickly thrust obliquely into this fold, so that the point enters 
 the subcutaneous tissues. Care must be taken to avoid entering a 
 subcutaneous vein, wounding a nerve, etc. The best situations for 
 hypodermic injections are over the deltoid muscle, on the outer 
 surface of the thigh or calf, in the buttocks, the loins, or the lateral 
 abdominal wall. No dressing is required for the needle puncture. 
 
 Use of Saline Solution. — The object of this solution is to supply 
 a fluid as nearly like the blood as possible. The following formula is 
 recommended by Park: 
 
 I^ — Calcium chloride, 2 parts 
 
 Potassium chloride, 3 parts 
 
 Sodium chloride, 9 parts 
 
 Sterile water, 1000 parts 
 
 This should be prepared aseptically and should again be sterilized 
 before use. In emergencies it is sufficient to add a teaspoonful of 
 
144 SURGICAL TECHNIQUE 
 
 sodium chloride (table salt) to each pint of water, boiling the solution 
 before using. This fluid is used hypodermically (hypodermoclysis), 
 by the bowel {yrodoclysis) , and by intravenous infusion. It is also 
 widely employed, especially in abdominal surgery, as a substitute for 
 sterile water. It should be injected at a temperature of from 110° 
 to 115° F. For hypodermoclysis, proctoclysis, or intravenous use, 
 it is convenient to let it flow out of a glass jar graduated from above 
 downward, so that a glance will show how much has been given. 
 In emergencies, a sterile fountain syringe or funnel will answer the 
 purpose. The main purposes for which it is used are to combat hem- 
 orrhage and shock by restoring blood pressure (p. 175), and to dilute 
 toxins circulating in the blood. 
 
 Hypodermoclysis.^ — This is the subcutaneous instillation of saline 
 solution. A long hollow needle, with large calibre, is used ; it is attached 
 to a rubber tube connecting with the receptacle, which may be several 
 feet higher than the patient. The clip on the tube is released, and, 
 while the fluid is running from the needle, this is thrust into the sub- 
 cutaneous tissues as in administering a hypodermic injection. The 
 best sites for hypodermoclysis are under the mammary glands, over 
 the lower border of the pectoralis major; in the flanks, the lateral 
 abdominal walls, or between the scapulae. From eight to ten ounces 
 may be introduced through one puncture, the accumulating fluid 
 being gently rubbed out into the tissues. Rarely more than one 
 quart is required by hypodermoclysis. The fluid is not absorbed very 
 rapidly, and where immediate effect is desired it should be given 
 intravenously. The needle punctures should be painted with collo- 
 dion and sealed with a scab of absorbent cotton. Under the term 
 axillary infusion has been described a method of hypodermoclysis by 
 which absorption is very rapid: a puncture is made, with a bistoury, 
 through the skin over the pectoralis major muscle about midway 
 between the clavicle and anterior axillary fold; then, with the fingers 
 of the left hand in the armpit as a guide, the hypodermoclysis needle 
 (not dangerous because blunt) is thrust through this puncture into 
 the cellular tissues of the axilla, traversing the pectoral muscle; the 
 solution is then allowed to flow. 
 
 Proctoclysis. — Proctoclysis, the rectal instillation of saline solution,^ 
 is widely employed in the treatment of peritonitis (Murphy, 1905). 
 A soft rubber catheter is attached to the rubber tube leading from the 
 reservoir, which should not be more than a few inches higher than the 
 patient's buttocks; the eye of the catheter is placed just within the 
 anus. The solution should flow into the rectum very slowly, about 
 a pint and a half every forty to sixty minutes for an adult. If a pint 
 and a half of the solution are placed in the reservoir every two hours, 
 eighteen pints will be absorbed in a day, and the rectum will have 
 periods of rest of an hour or more after each amount has been absorbed. 
 The catheter is to remain in place continuously. This treatment, may 
 
 1 Sterile water, without the addition of salines, is just as efficient; it is not 
 irritating to the bowel and is absorbed as readily (Trout, 1912). 
 
MIXOli SURIJEHY 145 
 
 1)0 coiitiiiiKMl Tor four or five days if necessary. If too inueli fluid is 
 administered, slight edema of the ankles, hands, and even face may 
 appear (Murphy). The sohition is j)hieed in the container hot (105° 
 to 110° F.), and may he kept hot by hot water hags (Fig. 805); but it 
 is probable that owing to its slow flow, it is about the temperature of 
 the blood or lower after traversing the tube to the ])atient. 
 
 Intravenous Infusion. The patient often is so shocked that no 
 anesthetic is required. A blunt pointed cannula is used, the eye being 
 bevelled to facilitate its introduction into the vein. Select a super- 
 ficial vein (usually the median cephalic at the elbow), and tie a tight 
 bandage around the extremity on the cardiac side of the vein selected, 
 in order to render it visible and fully disteniled. Prepare the skin 
 and your hands in the usual way. Then make an incision somewhat 
 obli(|uely to the course of the vein, about an inch long, and cut down 
 with light strokes directly on to the vein, which may be embedded in 
 fat. Do not tease and maul the fat; this favors infection of any 
 wound. When the vein is thoroughly exposed in this way, thrust a 
 grooved director across beneath the vein, and along the groove slip 
 two ligatures. Draw one of the ligatures to the distal side of the 
 grooved director and ligate the vein; draw the other ligature upward, 
 on the cardiac side of the director, and loop it but do not tie it tight. 
 Then pass a sharp scissors along the grooved director, and, controlling 
 the blood by a finger of the other hand on the cardiac side of the 
 director, cut the vein half way across (Fig. 96). Lay aside the scissors, 
 and take the infusion cannula in the right hand, have the clip removed 
 from the tube, and, while the saline solution is running from the 
 cannula, gently insert this into the gaping wound in the vein, point- 
 ing it toward the heart, and tie the ligature already placed so as to 
 secure the cannula in the vein. Then withdraw the grooved director 
 and have the bandage around the limb cut, so as to allow the venous 
 current to flow. The reservoir should not be held more than a foot 
 or two above the patient's body, and the saline sohition should not 
 flow more rapidly than a pint in ten minutes. The amount introduced 
 must depend on the state of the patient's pulse. Usually a quart is 
 more than enough: occasionally several quarts will be required. 
 
 Direct Transfusion. — This operation, introduced by Crile (1906), 
 implies the transference of blood directly from an artery of a healthy 
 person (known as the donor) to a vein of the patient (the recipient). 
 It has entirely superseded indirect transfusion, a method in which 
 blood was first drawn into a receptacle, then defibrinated, and finally 
 injected into the patient's veins. For the operation of direct trans- 
 fusion local anesthesia (cocain) should be used. Crile's technique 
 requires few special instruments beyond the silver cannula (Fig. 97) ; 
 hyi)odermic syringes and 0.1 per cent, cocain solution (Formula A, p. 
 156); scalpel, scissors, two rubber-covered artery clamps (Nunneley's 
 clips do very well), six fine bladed ("mosquito") hemostats, linen or 
 silk ligatures; as well as needles and suture material for closing the 
 skin wound. 
 10 
 
146 
 
 SURGICAL TECHNIQUE 
 
 Give })oth donor and patient a hypodermic injection of morphin 
 half an hour before the operation. Place the donor horizontally on 
 an operating table so arranged that its head may be lowered if the 
 
 Fig. 96. — Intravenous infusion of saline solution. 
 
 donor faints. Place the recipient on another table with his head 
 toward the donor's feet. Use cocain locally (0.1 per cent, solntion). 
 Expose first 3 cm. of the radial artery of donor, ligate distal and 
 clamp proximal end. Divide close to the ligature. By squeezing with 
 
 Fig. 97. — Direct transfusion of blood by moans of Crile's cannula. In the upper 
 illustration the vein is being drawn through the cannula by a sharp hook. In the lower, 
 the end of the vein has been everted and tied to the cannula, and the arterj^ is about 
 to be drawn over the vein. 
 
 fingers on the free (proximal) end of the artery, the adventitia is 
 made to project beyond the inner coats, and is cut off with scissors. 
 As the adventitia retracts, the muscular and endothelial coats are left 
 
MINOR SURGERY 147 
 
 projcctinj;. Cover tlie artery with gauze wet in liot saline solution. 
 Expose W to 4 cm. of a large superficial vein of the recipient, ligate the 
 distal and damp the proximal end; divide close to the ligature, and 
 remove the adventitia as above described. Pass the vein through the 
 cannula, which is held by a hemostat; I have found it easier to draw 
 it through with a fine hook (Fig. 97). P^vert the walls of the vein by 
 aid of mosquito hemostats, and ligate with linen or silk the everted 
 vein in the groove next the handle of the cannula. Then with the aid 
 of three mosquito hemostats, draw the artery over the end of the 
 vein, and ligate it around the other groove in the cannula. Unclamp 
 the vein; then unclamp the artery, and let the blood flow slowly. 
 The amount to be transfused depends on the reaction of both donor 
 and recipient. It is best to stop the flow so soon as the donor begins 
 to sigh, indicating respiratory embarrassment from the loss of blood. 
 Of course, if the recipient is brought to a satisfactory state by a less 
 amount of blood, less will suffice. It is truly astonishing to see the 
 color return to blanched lips, the lustre to the eyes, and to behold the 
 general hienseance which is produced by direct transfusion.^ 
 
 Phlebotomy. — Phlebotomy which is usually preferred to arteriotomy 
 for "letting blood," is generally done in the median cephalic or median 
 basilic vein. The vein is made tense by applying a tight bandage 
 above it, the skin is properly prepared, and a small incision (1 cm.) 
 is made directly over and into the vein. No anesthetic is required. 
 The spurting blood is caught in a suitable basin; it may be made 
 to run more freely by having the arm dependent or by directing the 
 patient to work his fingers around a bar, alternately tightening and 
 loosening his grip. The patient should be in a sitting posture, so that 
 any faintness may be quickly perceived. It is seldom desirable to 
 draw more than a pint. The wound is dressed with a pledget of 
 sterile gauze, no suture being required; and the same wound may 
 easily be reopened for further bleeding during the next few^ days. 
 
 Leeching. — The Swedish leech, which is preferred, draws from 
 three to four drams of blood. The skin is carefully washed, and the 
 leech applied over the part to be leeched, but not directly over a super- 
 ficial vein. If the leech does not bite, a little milk or blood should be 
 placed on the skin. When he has drunk his fill he will fall oft"; or this 
 may be hastened by applying salt over the leech and neighboring skin. 
 The blood usually continues to flow for some time, so that a much 
 larger quantity may be drawn from one leech bite than the capacity of 
 the leech. When enough has been drawn, the bite should be dressed 
 antiseptically, and moderate pressure applied. 
 
 Aspiration. — By means of a vacuum bottle it is easy to withdraw 
 fluid collections through a hollow needle. The bottle is first emptied 
 of^air as far as possible by the suction pump; the valves are then turned, 
 
 ' Several types of tubes (glass or metal, to be lined with paraffin before using) 
 are now on the market, by which it is thought the operation of direct transfusion 
 is rendered easier than by Crile's original technique; but I have had no personal 
 experience with them. Those of Brewer and of Bernheim are most popular. 
 
148 
 
 SURGICAL TECHNIQUE 
 
 and, the skin having been j)roperly ])repare(l, the sterile trocar and 
 cannula are thrust through the overlying tissues into the collection 
 of fluid (hydrothorax, empyema, cold abscess, etc.)- The trocar is 
 then withdrawn, the valve turned to close its passage, and the valve 
 leading from the cannula to the bottle is opened, allowing the fluid 
 to flow (Fig. 98). If the lumen of the cannula is blocked by flakes of 
 lymph, a stylet may be passed through it from time to time. The 
 puncture sliould 1 c dressed antiseptically. 
 
 Fig. 98. — Asjiiration of a luml>Mi 
 
 isrn],a] Hospital 
 
 ANESTHESIA AND ANESTHETICS. 
 
 Certain gases, which are respirable, induce unconsciousness when 
 absorbed through the lungs and carried to the nerve centres. The 
 state so produced is called general anesthesia. In addition to uncon- 
 sciousness, which implies analgesia and anesthesia, muscular relaxa- 
 tion is also produced.^ It is possible to secure the same effects from 
 some such drugs when administered otherwise than by inhalation, as 
 by rectal administration; but, as a rule, general anesthesia is secured 
 by inhalation of the vapor of ether, chloroform, ethyl chloride, etc. 
 Local anesthesia is produced by the local use of some drug, usually 
 introduced by hypodermic injection, which acts on the peripheral 
 ner^'es; cocain and eucain are most used for this purpose. 
 
 General Anesthesia. — The patient should have his bowels well 
 opened the day previously, and should have eaten no food for at least 
 eight hours befor the anesthetic is administered, as all general anes- 
 thetics, especially ether, produce some degree of nausea. In opera- 
 tions not involving the stomach or intestines, there is no objection 
 to the patient drinking a glass of hot water half an hour before the 
 operation. This prevents gastric irritation from any of the anesthetic 
 unavoidably swallowed. Before taking an anesthetic, a thorough 
 
 1 Crile has pointed out that general anesthesia secured in the usual way does 
 not prevent nocuous impulses from the seat of opeiation reaching the brain along 
 afferent nerves. If, however, the usual methods adopted to secure local anesthesia 
 are added to the general anesthetic these nocuous associations are avoided. To 
 this principle of operative surgery he has given the name Anoci-association. 
 
^AXESTinCSIA AM) AXK.STU KTICS 149 
 
 physical cxainiiiiitioii of tlir lu'iirt and Iiiti^'s should hv made, and the 
 l)atieiit should reino\e false teeth, ehe\viii<f <^imi, toi)aeeo, etc., from the 
 mouth as well as hairi)iiis, earrinj^s, etc. Home surgeons have the habit 
 of gi\iiig a hypodermic injection of morphin half an hour before com- 
 mencing; the anesthetic; in a few cases it is valuable, but frequently, 
 apart from beinji; a |)ure waste of a \ahial)le dru<;, it is actually harm- 
 ful. The clothes should be loosened around the throat and so dis- 
 posed as to make artificial respiration easy in case of emergency. 
 I)uring anesthetization and while recovering from the ef!'ects of anes- 
 thetics, the chests and shoulders of patients should be carefully 
 covered, as they are very prone to catch cold. No anesthetic should 
 be administered in the dark; change of color frequently is one of the 
 most easily recognized signs of danger, and unless the patient is being 
 anesthetized in a good light this cannot })e appreciated. The fre- 
 quency of ether deaths in negroes is probably due to inability to 
 recognize cyanosis readily in them. The patient should be supine, 
 with the head comfortably supported, especially in the old and round- 
 shouldered, in asthmatics, etc. Throughout the course of anestheti- 
 zation the anesthetizer must f)ay strict attention to his own duties, 
 and neither attempt to follow the minute details of the operation nor 
 to converse on irrelevant topics with bystanders. He is responsible 
 for the life of the patient quite as much as the surgeon; and it is a 
 sad fact that the disproportionate number of deaths from anesthesia 
 which occur during trivial operations is usually due to carelessness 
 of the anesthetist. With an ear for respirations, a finger on the tem- 
 poral pulse, and an eye on the patient's pupils, the anesthetist need 
 not fear to have his attention wander or to meet with unforeseen 
 accidents. 
 
 Ether is the safest general anesthetic for major surgery, and probably 
 is the most widely employed. Hewitt places its death rate at 1 in 
 16,000, five times safer than chloroform, though slightly less safe than 
 nitrous oxide. Ether (ethyl oxidej is a heavy, highly inflammable 
 liquid of strong pungent odor. Its vapor is heavier than air, and 
 sinks to the floor; hence all lights should be kept high above the 
 operating table, as occasionally patients have been seriously burned 
 by ignition of ether fumes. I prefer to administer it by the so-called 
 "open, drop-method," as follows: 
 
 The patient's cheeks, nose, and lips may be greased with vaselin 
 to prevent the rubefacient effect of the ether. Place eight to twelve 
 layers of dry wide-meshed gauze across the patient's mouth and nose, 
 and ask him if he can breathe through the gauze. He always answers 
 "yes." Then directing him to shut his eyes and mouth, and to breathe 
 through his nose, hold the gauze lightly in place, but do not exclude 
 all the air from under its edges; drop the ether gently over the gauze, 
 one drop every second or so, moistening an area an inch and a half in 
 diameter just below the tip of the nose (Fig. 99). When given thus 
 slowly very little if any respiratory irritation is produced, the patient 
 continues to breathe in his natural wav, and bv the time two ounces 
 
150 
 
 SURGICAL TECHNIQUE 
 
 have been administered he is usually unconscious, not having exhibited 
 any "stage of excitement." The lower jaw should be constantly held 
 forward by the fingers placed back of the angle, on the ramus, as 
 anesthesia paralyzes the muscles, and unless supported the jaw may 
 fall backward and allow the base of the tongue to force the epiglottis 
 over the larynx. When the respirations become mechanical, like 
 those of sleep, the pupils are found contracted but still reacting to 
 light and the conjunctival reflexes are abolished; then, after a little 
 more ether is administered muscular relaxation becomes complete. The 
 time consumed is usually from ten to fifteen minutes. The operation 
 may then be commenced.^ The time may be shortened by excluding 
 air more completely : this is easily accomplished by keeping the margins 
 of the gauze in contact with the patient's face, and by adding more 
 dry gauze on top and using it as a roof under which to drop the ether. 
 This concentrates the ether vapor, and requires less ether; but unless 
 cautiously and gradually done is apt to cause choking. The anesthe- 
 tist should never give enough ether to cause the pupils to dilate; if they 
 
 Fig. 99. 
 
 Hospital. 
 
 are kept contracted, but reacting to light, the patient is in the proper 
 state for operation. Frequently during the course of an operation it 
 may be possible to let the patient come so far from under the influence 
 of ether as to allow his pupils to return to their normal dilated state, 
 which should not be mistaken for the dilated state, without reaction 
 to light, present in ad^■anced ether poisoning. Some operators prefer 
 and others will not allow the anesthetist to let the patient "come 
 to" from time to time. Such idiosyncrasies must be learned by 
 experience. 
 
 In giving ether to children, who are not reasonable enough to lie 
 still and breathe quietly, it is better to pour a dram of ether at once on 
 the g&uze, and hold this firmly in contact with the face. After a short 
 
 1 Many very short operations (half a minute) may be done during the stage 
 known as "primary anesthesia,'' described many years ago by Packard. The 
 patient is directed to hold one arm aloft, when inhalation.^ are begun, and to hold 
 it up as long as possible. The moment the arm drops is the opportime time for 
 surgical intervention. In Germany this state of first insensibility from the 
 anesthetic is known as the "Ether Rausch." 
 
ANESTHESIA AND ANESTHETICS 151 
 
 striiji^lt', iiiid liokiiiij; tlic hrcatli until tli(jr()iif:;liiy "out of breath," 
 tiu' child will take a few deep ins])iratioiis, and hy so floing will pass 
 (•((inpletcly under the influence of the ether in a \ery much shorter 
 time and with \ery much less discomfort and danger to himself than 
 if tiie strug^de had been prolonged hy attempting to administer the 
 ether hy the droj)-method. 
 
 Certain accidcnh- may occur during etherization: (1) When ether is 
 first administered, the patient may stop breathing. This usually is 
 due to neglect of the precaution to start the patient breathing through 
 the gauze before any ether is dropped on it, or to pouring on a quantity 
 of ether instead of giving it drop by drop. It is treated by removing 
 the gauze, allowing the patient to breathe air, and then beginning 
 o\er again. (2) The patient, if an alcoholic, or if he has taken ether 
 frequently before, may be unduly exhilarated by the stimulating effect 
 of the ether. Hence it may be necessary to use forcible restraint, 
 and preparation should accordingly be made. So long as respiration 
 is good, the administration of more ether is indicated, as there are 
 very few patients, indeed, who do not succumb to its influence in a 
 short time. (3) The patient's throat may fill up with mucus, making 
 respiration difficult, and producing cyanosis. This generally is due 
 to too rapid administration of ether, to neglect to hold the jaw forward, 
 or to a preexisting bronchitis, etc. It is best treated by pulling the 
 jaw forward, as already described, thus opening the larynx; by turning 
 the head to one side, or letting it hang over the edge of the table, thus 
 allowing the secretions to accumulate in the cheek or to run out of 
 the mouth; and finally by the use of a mouth-gag with direct removal 
 of the mucus by sponging. The mouth-gag is rarely required by a good 
 etherizer; but it should always be at hand for emergencies. Marine 
 sponges are best for this purpose; each should be about an inch and 
 a half in diameter, freshly 
 wrung dry out of luke-warm 
 water, and fixed firmly in a 
 long handle. When the jaws 
 have })een opened by the 
 gag, the tongue is grasped 
 
 with gauze or a suitable for- Fig. lOO.— Tongue forceps. 
 
 ceps (Fig. 100), and pulled 
 
 forward and upward. This alone may make respiration easier. If 
 necessary, the sponges are to be passed back into the pharynx, and 
 by a combined sweeping and rotary motion are made to collect as 
 much mucus as possible. (4) The patient may stop breathing from 
 no foreseen cause. This frequently is due to the administration of 
 too much ether, occasionally to reflex inliibitiou from injudicious 
 traction on the tongue or sponging, and rarely to the direct shock of 
 the operation. It is treated by artificial respiration, by hypodermic 
 stimulation, and by inhalations of ammonia and oxygen when once 
 respiration is restored. (5) Vomiting occurs from neglect to abstain 
 from food before operation, but will not occur after anesthesia is once 
 
152 SURGICAL TECHNIQUE 
 
 complete, unless the patient is allowed to come out of the anesthetic 
 too far. 
 
 Chloroform. — One death among every 3749 chloroform anesthesias 
 is attributed to the action of the drug. Its action is more rapid than 
 that of ether, and the zone of safety is much narrower. It has been 
 said that the danger signals appear and the collision occurs at the 
 same instant; there is not sufficient warning, as there is in etheriza- 
 tion, for disaster to be avoided. The most important thing in chloro- 
 form anesthesia is to allow the mixture of plenty of air with the inhaled 
 
 vapor. On this account I 
 think the simplest way to 
 administer chloroform is by 
 dropping it slowly on one 
 or two thicknesses of gauze 
 stretched over a wire frame, 
 made to fit over the mouth 
 and nose in such a way that 
 the part of the gauze moist- 
 FiG. 101.— Chloroform inhaler. encd by the cliloroform is 
 
 always half an inch or more 
 di.-^tant from the patient's lips (Fig. 101). Even stricter attention to 
 the pulse and respiration is required than in giving ether; but a stage 
 of excitement scarcely ever occurs, little or no bronchial irritation is 
 produced, and vomiting during recovery from anesthesia is very 
 unusual. 
 
 Ethyl chloride is a seductive but dangerous anesthetic. It acts as 
 quickly as, and even more pleasantly than chloroform. 
 
 Xitroiis oxide, a gas which is universally employed for minor 
 dental operations, may be equally well employed in surgery for short 
 operations where complete muscular relaxation is not required. It 
 exerts its influence in less than a minute and is the least unpleasant 
 anesthetic to take. It acts largely by causing an accumulation in the 
 blood of carbon dioxide. Special apparatus is used, including a tank 
 containing the gas, a face mask with suitable valves to admit or exclude 
 air or oxygen in conjunction with the nitrous oxide, and a rubber 
 bag, inserted between the tank and the mask, in which the gas collects, 
 but from which the expired air is excluded by an automatic valve. 
 When a suitable admixture of oxygen is permitted, skilful anesthetists 
 may prolong the duration of anesthesia for an hour or more. Nitrous 
 oxide frequently is used to induce anesthesia, ether or chloroform being 
 substituted later. As I have seen it used in this way I have not been 
 able to see any advantages over the skilful administration of ether 
 from the start; but when nitrous oxide and oxygen are used alone, 
 without any recourse to ether, recovery from the anesthetic occurs 
 much more promptly, and there are no unpleasant after-effects. 
 
 Clioice of a General Anesthetic. — Unless contraindicated, ether is 
 to be preferred, because it is the safest. Its greatest danger is post- 
 operative bronchitis or pneumonia ; but with proper precautions against 
 
ANESTHESIA A.\D ANESTHETICS 153 
 
 exposure of the patieijt, and 1)\' ,u;i\iii<i; it drop !)>• drop, such com- 
 ])Hcations are not to l)e feared. Moreoxcr, it is Ixtter for a patient 
 to he nauseated and to ha\'e hronchial irritation after reeo\ery from 
 etlier than for liini to he killed hy chloroform or ethyl chloride. In 
 cases where bronchitis, phthisis, etc., exist, or where the kidneys are 
 seriously diseased, and where some general anesthetic has to be 
 employed, nitrous oxide and oxygen should be ])referred. Chloroform 
 is particularly to be avoided in cases of heart lesion not properly 
 compensated, and in cases of shock. Nitrous oxide causes cyanosis, 
 stertor, and muscular regidity, with such increase of blood pressure 
 that it is esj)ecially contraindicated in patients with arteriosclerosis; 
 its successful administration requires much more skill and experience 
 than does that of ether, but when skilful assistance is available, and 
 the operation will not consume more than thirty or forty minutes, it 
 is when combined with oxygen a safer and more desirable anesthetic 
 than is ether for patients with visceral lesions other than those of the 
 vascular system. 
 
 Administration of General Anesthetic for Special Operations. — Head 
 AND Neck. — It is found often in operations on the head and neck 
 that the anesthetist is very much in the way, and that the progress 
 of the operation interferes with the proper administration of 
 the anesthetic. One of the simplest methods of o\ercoming this is 
 to have the ether vapor conducted to the patient's mouth through 
 a tube, so that the anesthetist may stand at some distance. This is 
 accomplished by standing the ether bottle in a pan of warm water, 
 to increase the rapidity of vaporization. Through the cork of the 
 ether bottle pass two tubes — an afferent tube which is connected 
 with a hand bulb, and an efferent tube Avhich is three or four feet long 
 and leads to the patient's mouth. If a hooked metal tube is attached 
 at the mouth end, it will hang in the angle of the mouth and keep its 
 place without difficulty. The ether vapor has never caused, in my 
 experience, any evidence of stomatitis. If its irritating effects are 
 feared, the vapor may be conducted by tube over or through a 
 bottle of water before entering the mouth. The patient is first 
 anesthetized in the usual way, and when thoroughly relaxed, the 
 gauze is removed from the face, the mouth tube introduced, and the 
 ether vapor forced into the mouth by use of the hand bulb. 
 
 Crile's plan is another convenient method. After the patient is 
 anesthetized, the surgeon passes a well greased tube through each 
 nostril to the naso-pharynx, and packs the mouth loosely with gauze. 
 The outer ends of the nasal tube are connected by a Y-shaped glass 
 tube to a long rubber tube, at the far end of which is a funnel lightly 
 filled with gauze. The ether is then administered by being dropped 
 on the gauze in the funnel. It is well to ha^'e a U-tube inserted 
 somewhere in the tube which conducts the ether vapor to the patient, 
 so that in it may collect any condensation from the ether vapor. 
 
 IxTRATHORACic Operatioxs. — When the pleura is opened, the lung 
 partially collapses, and in consequence there may be considerable 
 
154 SURGICAL TECHNIQUE 
 
 respiratory <listiir})aiice and interference with the a(hninistrati()ii of an 
 anesthetic. To overcome this Sauer])rnch, of Breshm, devised (11)04) 
 a plan for operating nnder negative atinuspheric 'prcwure, thns allowing 
 the Inng to remain expanded. In this method the patient is i)laced 
 in a chamber in which negative pressure can be induced; his head 
 projects through an opening in this chamber, and a rubber collar 
 fitting closely around his neck makes the aperture air-tight. The anes- 
 thetist sits outside the chamber, while the surgeon and his assistants 
 must remain inside. This plan of operating under negative pressure 
 entails expensive apparatus, and a specially constructed operating- 
 room, which cannot be moved from place to place. Dr. Willy Meyer, 
 of New York, is the chief supporter of the method in America, and 
 has had a very complete operating suite constructed in the German 
 Hospital in that city. 
 
 Positive Pressure Method. — This was introduced by Brauer, of 
 Heidelberg, very soon after Sauerbruch's method. Here the patient's 
 head and the anesthetist are in a specially constructed chamber, 
 in which the atmospheric pressure may be increased, by suitable 
 apparatus, so that when the pleural cavity is opened the lung stays 
 expanded. This appears to be a simpler method than that of negative 
 pressure, and seems quite as efficient; but has not been used much 
 in this country. 
 
 Intratracheal Insufflation. — Meltzer and Auer, of the Rockefeller 
 Institute, New York, found in experiments on dogs, in 1909, that if 
 a tube was passed down to the trachea almost to its bifurcation, and 
 if air mixed with ether was constantly blown in through this tube by 
 suitable bellows, the dog's lungs remained expanded even when both 
 pleurae were widely opened, that anesthesia could be maintained for 
 hours, and that it was impossible to kill the dogs by an overdose of the 
 anesthetic. This method was adapted for human beings by Elsberg, 
 of New York, and is now the most approved plan for administering 
 an anesthetic for operations on the lung, the thoracic esophagus, the 
 cardiac orifice of the stomach and the diaphragm. It is a great con- 
 venience also in operations on the mouth and pharynx, as it prevents 
 aspiration of mucus or blood. Briefly described, the apparatus is as 
 follows : An electric motor is used to pump the air through a bottle 
 of warm water, by which it is filtered, warmed, and moistened. The 
 air is then conducted by tube to the ether bottle, where the tubing is 
 so arranged with stopcocks that (1) all the air may pass directly on 
 to the patient without coming into contact with the ether; (2) all the 
 air may pass through the ether bottle, over the surface of the ether, 
 and thus become saturated with the anesthetic before reaching the 
 patient; or (3) some of the air may pass directly on to the patient 
 while some passes through the ether bottle before reaching the 
 patient. Thus the amount of ether to be administered may be accu- 
 rately regulated. An oxygen tank maybe connected with the tube 
 leading to the patient, so that pure oxygen or oxygen mixed with air 
 in any proportion may be inhaled. 
 
ANESTHESIA AND ANESTHETICS 1.').') 
 
 Tlie tiilx' leadinj; from the ether bottle to the patient is eonneeted 
 with a iiiaiiometer, and lias a ^ -cndinji, one branch tor connection with 
 the intratracheal tube, and the other to be used as a cut out, to allcjw 
 collapse of the lungs at any instant desired. The ai)paratus may be 
 obtained now in very compact form. 
 
 The intratracheal tube should be fairly rigid, of the length of a 
 stomach tube, and about half the diameter of the trachea. The 
 patient is anesthetized in the usual manner, and the larynx and 
 pharynx are thoroughly anesthetized with coeain solution (10 per 
 cent.). The tube, previously sterilized, is then passed through the 
 lar>nx into the trachea. This is facilitated by the use of a broncho- 
 sc-opic tube or speculum. When the intratracheal tube is momentarily 
 arrestefl at the bifurcation of the trachea, it is withdrawn a})out an 
 inch. If the tube is in correct position air will enter both lungs; if 
 it has been pushed in so far as to be arrested at the division of the right 
 bronchus no air will enter or leave the left lung. ^Yhen in ])roj)er posi- 
 tion, the tube is clamped just outside the dental margin by a frame 
 supported on the ears, resembling a spectacle frame. "The tul)e is 
 now connected with the air pressure apparatus, and air is blown 
 through at a pressure of 10 mm. of mercury. After several minutes, 
 the pressure is raised to 20 mm. and the operation can be begun. 
 When the pressure of the inflowing air and ether equals 20 mm. of 
 mercury, inspiration and expiration will continue, air being inhaled 
 and exhalkl by the side of the tube. If there existed a profuse secre- 
 tion of mucus in the pharynx and trachea, this will be found to have 
 ceased soon after the insufflation was begun. Every two to three 
 minutes, an assistant opens a vent so that the current of air which 
 enters the tube is interrupted for a moment." (Elsberg.) 
 
 Xo ill eft'ects have been noted from anesthesia maintained by this 
 method. F'ar from favoring pulmonary complications, it seems to 
 prevent them. 
 
 Local Anesthesia may be secured by freezing the skin with a mix- 
 ture of ice and salt, or by a spray of ethyl chloride or rhigolene. The 
 skin becomes white, covered with minute crystals of ice, and is rendered 
 very tough. The anesthesia lasts only a few seconds, but sufficiently 
 long for opening superficial abscesses, etc. If the patient only knew 
 that freezing hurts as much or more than a sudden stab with a sharp 
 bistoury, he probably would prefer to have this form of local anes- 
 thesia abandoned. 
 
 Coeain and eiicain are the chief agents used for local anesthesia. 
 Solutions of coeain are unstable chemically, and are destroyed by 
 repeated boiling; in emergency, boiling for a few minutes does not 
 impair their value. Eucain {eucain B) is not so toxic as coeain, is 
 not destroyed by boiling, and is quite as efficient; but the duration 
 of anesthesia is shorter than that produced by coeain. In general, 
 eucain is to be preferred. The addition of saline solution, to make 
 the solution isotonic with the blood, and of adrenalin to constringe 
 the capillaries, thus preventing diffusion of the anesthetic and local 
 
156 SURGICAL TEmXIQUE 
 
 edema, renders the use of local anesthesia much more satisfac- 
 tory. The apphcation of an Esmarch band above the seat of 
 operation also prevents diffusion of the anesthetic. Cocain tablets 
 which can be sterilized by dry heat, are now on the market. Mitchell 
 (190Sj recommends that each tablet be sterilized in a glass flask as 
 needed, being added to the sterile saline solution just beff>re it is to 
 be used. Finally, the adrenalin solution is to be added drop by drop 
 to the required amount. He gives the following formulae from Braun: 
 
 A. 
 Cocain hydrochlorate, 0.1 grm. (1.5 grain) 
 
 Physiologica] salt solution, 100 c.c. 
 
 (jTT per cent.t 
 Adrenalin (1 to 1000) 5 drops. 
 
 B. 
 Cocain hydrochlorate, 0.05 grm. (0.75 grain) 
 
 Physiological salt solution 5 -cc. 
 
 (tV per cent.) 
 Adrenalin (1 to 1000) 10 drops. 
 
 Formula A represents a 1 to 1000 cocain solution, anrl may be further 
 diluted with saline solution if large amounts are to be used, as in long 
 operations by Schleich's infiltration anesthesia; while Formula B (a 
 1 per cent, solution of cocain) is used for operations requiring only one 
 or two h^•podermic injections, when the whole amount of the formula 
 may be employed safely. For applications to mucous membranes 
 (eye, throat, urethra, bladder;, a 2 per cent, solution may be used, 
 and sometimes a 4 per cent, solution. It is dropped on the surface of 
 the eye, and is applied to the nose and throat by a pledget of absorbent 
 cotton: while it is injected into the urethra and bladder by means 
 of the urethral syringe, catheter, or in.>tillator. 
 
 Hypodermic Use. — The skin is pinched up as in giving a hypodermic 
 injection, but the needle, which enters at one end of the proposed 
 incision, with its point directed toward the other end, is not passed 
 into the subcutaneous tissues, but its point is arrested in the true skin, 
 the first injection being endodermic, not hypodermic. As the piston 
 of the syringe is pushed down, a distinct wheal is raised in the 
 skin; the needle is then pushed on within the true skin until its 
 point reaches the limit of the wheal, when another wheal is pro- 
 duced, and so on until the entire length of the needle has entered. 
 It is then withdrawn and reintroduced at the furthest point reached, 
 and the process is repeated until the line of the entire incision has 
 been anesthetized. An incision may then be made through the skin, 
 and, with a few added drops here and there as required, this degree of 
 anesthesia will suffice for circumcision, removal of sebaceous cysts and 
 small tumors, opening cold abscesses, etc. For such cases Formula B 
 may be used. When a more extensive operation is imdertaken, as 
 one for hernia, goitre, etc., it is best to use the weaker solution (dilu- 
 tions of Formula A), and special attention must be paid to nerves, 
 bloodvessels, and connective tissue bundles (infiltration anesthesia). 
 Almost any quantity of the weaker solutions may be used, especially 
 
ANESTHESIA AM) ANESTHETICS 
 
 157 
 
 when local aiu'stlicsiji is aided by constriction of the linih al)o\'e the 
 seat of operation. 
 
 Nerve hloek'uuj may he acconij)lishe(l l)y perineural or endoneural 
 injections, the latter being preferable as more accurate and permitting 
 a wider range of o])erative procedure. Certain nerves (ulnar, jjer- 
 oneal) may be reached directly, but usually it is necessary to bare 
 the ner\e by the hypodermic use of cocain as already described. In 
 the endoneural method ((Vile, Pushing, IMatas), the cocain is injected 
 directly among the nerve fibres of the main trunks conveying sensa- 
 tion from the region to })e operated on. Comjjlete anesthesia follows, 
 and as no sensory impulses can reach the nerve centres surgical shock 
 is nuich diminished or totally prevented, a fact which is of value in 
 many amputations. I generally employ 2 per cent, solutions for this 
 purpose. 
 
 Fig. 102. — vSpinal analgesia. Needle between spines of second and third lumbar 
 vertebrae. Posterior superior iliac spines marked with iodin. Episcopal Hospital. 
 
 Spinal anesthesia is closely allied to nerve blocking. It was sug- 
 gested in 1885 by Leonard Corning, of New York; was employed in 
 1889 by Tuffier; and has been more widely used abroad than in this 
 country. The anesthetic acts on the roots of the spinal nerves, not on 
 the cord itself. The injection is made usually in the second or third 
 lumbar interspace (Fig. 102); as a rule, anesthesia (which aflFects both 
 motor and sensory impulses, especially the latter) extends only to the 
 region of the waist, and therefore operations best suited for spinal 
 anesthesia are those on the lower extremities or pelvis. Stovain (4 
 per cent, solution) usually is preferred to other anesthetics, and is 
 that which I am myself accustomed to use. About 1.5 to 2 c.c. are 
 employed. The anesthesia begins in a few minutes and lasts nearly 
 an hour. As positive contraindications to spinal anesthesia may be 
 mentioned: advanced cachexia, bilateral nephritis with scanty excre- 
 tion, myocarditis, pericarditis with effusion, non-compensated cardiac 
 disease. ]\Iany operations in which spinal anesthesia may seem 
 desirable can be done equally well under local anesthesia ; but for rectal 
 operations and prostatectomy spinal anesthesia is to be preferred, if 
 a general anesthetic cannot be employed. 
 
158 SURGICAL TECHNIQUE 
 
 Vein anesthesia is a term used to describe a method employed by 
 Bier (1908). He has used it in 134 operations. It is appHcable to any 
 operation on the extremities. He first renders the part bloodless by 
 Esmarch's method (p. 433), and cuts off the general circulation by 
 broad elastic bands above and below the seat of operation; exposing 
 then a superficial vein, he injects into the vein 40 to 80 c.c. of a 0.5 
 per cent, solution of novocain in saline solution; the solution diffuses 
 through the capillaries of the area sequestrated from the general 
 circulation, rendering every subsequent manipulation painless. At 
 the conclusion of the operation the anesthetic solution may be removed 
 by washing out the veins with saline solution, but this is not always 
 necessary, as most of the novocain escapes into the wound through 
 the capillaries dividt d during the operation. 
 
CHAPTER VI. 
 INJURIES AND THEIR EFEECTS. 
 
 LOCAL EFFECTS OF INJURIES. 
 
 The local effects of injury depeiid on the part injured, as well as 
 on the force exerted by, and the manner of action of the vulneratin<i; 
 body. A smart blow with a rope will produce a wheal; if the roi)e 
 slips rapidly through the hands with violent friction, a l)rush-})urn 
 will result; but if the rope is twisted tightly around the part, strangula- 
 tion will occur. Striking the foot against a large stone will cause a 
 contusion, but if the same stone falls on the leg it may fracture the 
 bones. Injury of parts with abundant and lax subcutaneous tissues 
 will be attended by much greater swelling than where these tissues 
 are firm and resistant; injuries of certain 
 parts are much more dangerous than 
 similar or severer injury expended upon 
 other parts not so highly specialized or so 
 vascular. 
 
 The local efi'ects of heat, cold, etc., are 
 considered in Chapter IX. 
 
 Abrasions. — An abrasion is an injury in 
 which merely the epiderm has been re- 
 moved by slight friction; brush-burns, 
 produced by violent friction, resemble 
 contused wounds (p. 167). An excoriation 
 is an injury produced by scratching or 
 scraping which involves the corium. The 
 resulting ulcers heal readily when properly 
 protected. 
 
 Contusions. — A contusion is a subcuta- 
 neous injury of the soft parts produced by 
 blunt force (kicks, falls, etc.). There is al- 
 ways a certain amount of blood extravasated 
 among the lacerated tissues; when this 
 blood is visible in moderate amount be- 
 neath the skin, it is termed an ecchymosis; 
 and as it undergoes absorption it passes 
 
 through various shades of purple, green, black, and blue. A very 
 minute ecchymosis is called a petechia. Bloofl extravasated beneath 
 the conjunctiva remains bright red a long time, owing to oxidation 
 through the thin overlying tissues. When enough blood is extrav- 
 asated to cause an appreciable collection of fluid, it is called a 
 
 Fig. 103.— Hciiial«.i,,:i .ii left 
 thigh ten clays after a full ; aldo 
 fracture of shaft of left hu- 
 merus. Age forty-eight years. 
 Episcopal Hospital. 
 
160 INJURIES AND THEIR EFFECTS 
 
 hematoma; or if clotted a thrombus. The skin itself, though more 
 resistant than the subcutaneous tissues, does not always escape 
 injury in a contusion; such injun- is manifested in the course of 
 twelve to twenty-four hours by vesicles, blisters, and bullae. These 
 usually appear before the ecchymoses, which rarely become apparent 
 until the second or third day. The diacpiosis of a contusion is easy, 
 being based on the history of injury by blunt force; on the indentation 
 of the soft parts (especially on the scalp), often persisting when the 
 patient is seen soon after the accident; on the local tenderness which 
 is rapidly followed by swelling, extravasation, and ecchymosis. The 
 yrognosis is good, unless there is some undetected injury to nerves, 
 bloodvessels, bones, joints, or internal organs. The hematoma which 
 forms seldom causes anxiety; usually the bleeding ceases spon- 
 taneously, or under the application of cold, elevation of the part, 
 moderate pressure, etc. The treatment consists in securing local rest, 
 in applying anodyne or slightly stimulating fomentations (arnica, 
 dilute alcohol, ichthyol ointment), and in promoting absorption of 
 the hematoma at a later date by gentle massage, firm bandaging, 
 etc. Constitutional treatment is rarely required. 
 
 Strangulation. — Strangulation of a part results from the inter- 
 ruption of the circulation by the application of circular constriction 
 so tight and sufficiently long as to cause passive changes somewhat 
 resembling those seen in contusion. If the strangulation is not 
 relieved (by elevation, by division of constricting bands, etc.), the 
 part dies, and is removed as a slough by granulations at the point of 
 constriction. All the dangers from infection, present in gangrene 
 from other causes, arise, and life is occasionally lost. 
 
 Wounds. — A wound is a solution of continuity of the soft tissues 
 the result of violence. A wound is open if the skin is as widely divided 
 as the underlying structures; or suhcutaneous if the division of the 
 skin is insignificant. Wounds are also described as incised, lacerated, 
 contused, punctured, or poisoned. Gunshot wounds, which resemble 
 contused wounds, are considered in Chapter VII. 
 
 Incised Wounds. — Incised wounds, which may be regarded as the 
 normal type, are those made by clean cuts with sharp instruments, 
 and are produced by the surgeon in every cutting operation. ]\Iost 
 accidental wounds partake more of the nature of lacerated than 
 incised wounds, as the instruments by which they are inflicted (pocket 
 knives, broken glass, axes, etc.), are not as sharp as surgical instru- 
 ments, and even if sharp (as razors) are not wielded with the delicacy 
 and precision necessary in surgery. Pain, hemorrhage, and gaping 
 are the main symptoms of incised wounds. The pain varies with 
 the size of the wound, with the sensibility of the part wounded, and 
 with the manner in which the wound is produced. A large wound 
 hurts more than a small one; wounds of the face and hands hurt 
 more than those of the back and buttocks where the cutaneous nerves 
 are less developed; and a quickly made incision causes less pain 
 than one which is bungled. The hemorrhage depends largely on the 
 
IXCISED WOUXDS 1()1 
 
 location of the wound, and on the inij)Hcation of hirj^e vessels. Wounds 
 of tlie face and scalj) bleed profusely, because of the vascularity of 
 these ])arts. and because in the scalp the vessels cannot contract 
 and retract. The uai)int,' of a wound (lejx'nds on the natural elasticity 
 of the tissues dixided. A wound which runs in the direction of the 
 natural folds of the skin will ^'ape less than one which crosses these 
 folds; one which divides muscles transversely will gape widely; the 
 divided ends of tendons, arteries, and nerves may retract for several 
 inches from the ])oint of division. 
 
 Pnxr.s-s of IliaJing in Incised Wounds. — As the result of tiie irrita- 
 tion produced by the vulnerating body, tissue changes occur which 
 are pathologically identical with those seen in the process of inflam- 
 mation; so that the healing of an incised wound is the same as Repair 
 after Inflammation (p. 29). It is convenient to recognize different 
 ways in which union occurs after a wound has been inflicted, although 
 the ditterence is purely quantitative, depending on the extent of 
 reaction necessitated, and though the processes, so far as they extend, 
 are identical in all cases. Historically, three ways of union are recog- 
 nized: (1) By immediate union (to which the term "first intention" 
 as used by Hunter (1784)^ is correctly applied); (2) by adhesion, as 
 understood by Paget (1853); and (3) by granulation, or by second 
 intention. 
 
 1. Immediate Union. — If the edges of an aseptic incised wound 
 are accurately apposed so that each tissue meets its corresponding 
 structure in the other lip of the wound; and if no foreign particles, 
 even if aseptic, or no blood-clots, remain between the lips of the 
 wound, then the reactive process may extend only to the stage 
 described as that of "temporary hypertrophy." No inflammatory 
 lymph is exuded, no granulation tissue forms, and the wound heals 
 by immediate union, or by the first intentiow^in the Hunterian sense. 
 Very few incisions and yet fewer wounds heal by immediate union; 
 very small wounds of extremely vascular parts (fingers, face), may 
 occasionally heal without the process of reaction having extended 
 beyond the stage of temporary hypertrophy. Such wounds when 
 healed leave no visible scar — the tissues have undergone complete 
 regeneration, restitutio ad integrum. 
 
 2. Union by Adhesion. — When the insult to the tissues has been 
 greater, or when the tissues themselves have been less able to repair 
 the damage, the process of reaction extends to the stage of lymph 
 formation. The lips of the wound must be in accurate apposition, 
 leaving no dead spaces, so that the effused inflammatory lymph 
 serves as a framework in which fibroblasts and granulation tissue 
 develop, as described at p. 30. It is this form of union which occurs 
 in the vast majority of aseptic operative incisions, and which is com- 
 monly spoken of as "union by the first intention," though strictly 
 speaking this term should be reserved for immediate union; but as 
 
 ' It is the "first intention" of nature to heal wounds in this way. 
 11 
 
162 INJURIES AND THEIR EFFECTS 
 
 for at least seventy years it has been erroneously applied by the 
 majority of surgeons, it is perhaps useless to register a protest now. 
 In the process of union by adhesion a scar is always produced extend- 
 ing to the depths of the incision, but is least conspicuous in wounds 
 made with the greatest precision and attended by the least trauma; 
 so that the kind of scars left by a surgeon in operating often gi\-e an 
 idea as to the delicacy and neatness of his operative methods. 
 
 3. Ujiion by Granulation. — This form of union, also known as 
 union by the second intention, is that which occurs when the reaction- 
 ary process extends to the stage of pyogenesis. As already pointed 
 out (p. 27), it is theoretically possible for pus to be formed without 
 the intervention of microorganisms; and it is likewise theoretically 
 possible for wounds to unite by granulation without the formation 
 of any visible pus: but for either of these events to occur in practice 
 is excessively rare. If the lips of the wound are not brought into 
 accurate apposition, the gaping surfaces become covered with visible 
 granulations, and always, I believe, some pus will be seen on the 
 surface of the healing wound (which really is' an ulcer), or will be 
 absorbed by the dressings. The process of cicatrization and con- 
 traction is pathologically identical with that seen in the healing of 
 ulcers (p. 53). Union by secondary adhesion (the third intention) is 
 that which occurs when two lips of a granulating wound are apposed 
 by sutures, or in other ways, so that the fibroblasts and granulations 
 on one lip grow across the obliterated gap into the granulation tissue 
 on the opposite lip, thus hastening the process of repair. If there 
 is much discharge from the wound such secondary adhesion will 
 not occur. Healing by scabbing, by incrustation, or by subcrustaceous 
 cicatrization, is that form of union (l)y adhesion or by granulation) 
 which occm"s under a scab formed of effused blood and lymph mixed 
 with the dust, etc., which collects on the surface. 
 
 Treatment of Incised Wounds.- — The first effort must be to check 
 hemorrhage and to prevent infection. In operating, aseptic or anti- 
 septic principles will be strictly adhered to, and in wounds accidentally 
 received the surgeon, after adopting the necessary measures for 
 arresting hemorrhage (Chapter X) will employ such methods of 
 cleansing the wound and the surrounding parts as have already been 
 advised in Chapter V (p. 140). Very small wounds will gape so little 
 that the proper use of plasters, compresses, bandages, etc., will keep 
 the edges in contact. In most wounds, however, the edges must be 
 united by sutures. 
 
 Sutures are made of absorbable or of non-absorbable material. 
 Absorbable sutures are usually made of catgut, which may be pre- 
 pared in such a way that it will last a more or less definite time in 
 the tissues before being absorbed (10-, 20-, and 40-day chromicized 
 catgut). Non-absorbable sutures are made of linen, silk, silkworm 
 gut, silver wire, etc. Interrupted sutures are shown in Fig. 104, each 
 separate stitch being independent of every other stitch. Varieties 
 of the interrupted suture are the twisted, or hare-lip suture (p. 636), 
 
METHODS OF SUTURE 
 
 1G3 
 
 and tlic quilli'd suture (Fij,'. 105). Continuous sutures are those in 
 which several or all of the individual stitches are made l)y one thread 
 which is knotted only at the beginning and end of the line of suture. 
 \'ari()us forms of contimious suture are used in surgery; the overhand 
 suture (Fig. UK)) is most frccjucntly used, and is well adapted for 
 uniting edges of fascia, skin, etc., on which there is not much tension; 
 
 -i r\ a i 
 
 Fig. 104. — Iiitcrruptod sutures; each 
 stitch is knotted separately. 
 
 Fig. 1U.5. — Quilled sutures; each stitch 
 is double and tied over a quill, or prefer- 
 ably a rubber tube, which prevents the 
 stitches from cutting. Useful when there 
 is much tension on the sutures. 
 
 Fig. 106. — Continuous (overhand) suture. 
 
 Fig. 107. — Chain or lock-stitch. 
 
 Fig. 108. — Quilt or mattress suture. 
 
 Fig. 109. — Sutures u.sed to repair a deep 
 wound: A, superficial suture (through the 
 skin only) ; B. deep suture (passing deeply 
 into the wound, but not a buried suture) ; 
 c, c, buried sutures (to unite peritoneum, 
 deep fascia, etc.). 
 
 Fig. 110. — Figure-of-eight suture, em- 
 ployed to unite parietal peritoneum, deep 
 fascia and skin. 
 
 the chain or lock-stitch (Fig. 107) is useful where tension is greater; 
 while the quilt or mattress suture (Fig. 108), by passing deeply into 
 the tissues, is useful where there is tension on the deeper parts, as 
 it tends to evert the lips of the wound. Other forms of continuous 
 suture are used in intestinal surgery (Chapter XXII). A suture may 
 be superficial, deep, or buried, as shown in Fig. 109. As a rule only 
 absorbable material should be used for buried sutures. Deep sutures, 
 
104 
 
 INJURIES AND THEIR EFFECTS 
 
 also called mass sutures or splint sutures, are used to relieve tension 
 (relaxation .futures), and to obliterate dead si)aces in the depths of a 
 wound in which it is not desirable to leave buried sutures; they must 
 be strong and therefore are usually of non-absorbable material. 
 The figure-of-eight suture (Fig. 110) is employed by some surgeons 
 as a deep suture. 
 
 Needles. — Straight needles are most generally useful, except for 
 inserting buried sutures, for which curved needles are to be preferred. 
 
 Curved needles usually are held in a 
 needle-holder (Fig. Ill), but straight 
 needles are easily managed in the 
 fingers. Ordinary surgical needles are 
 made with a triangular or a lance-shaped 
 
 Fig. 111. — A convenient form of 
 needle-holder. 
 
 • A 
 
 A B 
 
 • C 
 
 J) 
 
 Fig. 112. — Various forms of needles. A, 
 straight round-pointed needle. B, straight 
 lance-pointed needle. C, curved round-pointed 
 needle. D, curved lance-pointed needle. 
 
 -point, to facilitate their introduction; hwt round needles (either straight 
 or curved) are used in intestinal work, as less liable to cause hemor- 
 rhage or to allow fecal leakage through the puncture (Fig. 112). The 
 eye of a needle should be large enough to be threaded easily with the 
 suture desired; and the widest part of the needle (belly) should be 
 
 Fig. 113. — 1. Reverdin's needle, showing at a eye opened, at h eye closed. 
 2. Ordinary mounted needle. 
 
 situated where the cutting edges ceases, not on the shaft or at the eye 
 itself. Special forms of needles are set in handles, and have the eye 
 near the point: the aneurysm needle (p. 232) has a blunt point, and 
 is used to pass ligatures around large ^•essels; the ordinary nioitnted 
 needle has been modified b\- lieverdin by inserting a slide by which the 
 
SUTl'RES AM) KXOTS 
 
 165 
 
 eye may he ojxmumI to facilitate tlir('a(!iii<;' ( l^'i^- lli!), and is useful 
 ill |)assiii^- (leejr sutures. 
 
 Siifnrc of W tin mis. Su[)erli(ial woiiimIs may \)v uuite(l with super- 
 ficial sutures (tuly; if the deep fascia is dixided, it should he united 
 with either deep or l)uried sutures, as the suhsecpieut strenj^th of 
 the |)art dej)ends lar<iely upon the accuracy with which this structure 
 is sutured, and e\eii in parts where strengtii is not requisite (us in 
 
 the neck) neglect to suture the 
 deeper layers carefully results 
 in a spreading instead of a 
 linear cicatrix. l)i\ ided tendons, 
 nerves, etc., should l)e sutured 
 separately by buried sutures. 
 In extensive wounds, especially 
 where the tissues have been 
 much bruised, either by the in- 
 jury or during the operation, 
 it usually is desirable to pro- 
 vide for drabuKje, to allow the 
 
 Fig. 114. — The sriuaro or reef knot, uni- 
 versally employed. Note that correspond- 
 ing ends of the ligature pass under (or 
 over) the loop of the knot. 
 
 Fig. 115. — The surgeon's knot; em- 
 ployed rarely-, hut useful if the first hitoh 
 of the knot tends to slip before the seeond 
 can be pulled tight. The same as the 
 square knot exeejjt that the first hitch is 
 double. 
 
 Fig. 116.— The granny knot. Note that 
 of corresponding ends of the ligature one 
 passes over and the other under the loop 
 of the knot. 
 
 Fig. 117. — The subcuticular suture; 
 it may be used if no dead spaces are left 
 in the deeper parts of the wound. The 
 needle enters the true skin at each bite, 
 not merely the subcutaneous tissues. 
 
 escape of effused blood, lymph, etc., which would retard healing if 
 allowed to remain l)etween the lips of the wound, and perhaps 
 cause sloughing from pressure if not evacuated. Hence the im- 
 portance of accurate hemostasis in all wounds, especially where 
 drainage is undesirable (as in operations for radical cure of hernia). 
 Xo dead spaces should be left in repairing wounds: they will be filled 
 by blood-clot, and this will be a suitable culture medium for germs. 
 
1G6 INJURIES AND THEIR EFFECTS 
 
 Sutures must be drawn just tight enough to a])pose the edges of 
 the wound without constricting the tissues. Drawing a suture too 
 tight may break it, or may cause sknighing with a resulting stitch 
 sinus. Sutures are secured in position b\- knots, or occasionally by 
 clam])ing them with jjerforated shot. The knot employed should 
 be one that will not slip, especially the square or reef knot (Fig. 114), 
 or the surgeons knot (Fig. 115), never the granny knot (Fig. 116). 
 Some surgeons employ little metal clamps (Michel) to appose the 
 skin margins, instead of sutures; or a subcutlcnlar suture may be 
 used (Fig. 117). 
 
 Dressing of Incised Wounds. — On the surface of nearly every 
 wound there will be a slight exudation of serum between the sutures; 
 to prevent the dressings from sticking to the wound it is therefore 
 well to cover it with silver-foil, or to dust it with some sterile powder. 
 Aseptic wounds may be dressed with aseptic gauze, that next the 
 incision being crumpled up so as more readily to absorb any dis- 
 charges, while the outer layers of gauze are applied smoothly and 
 in sufficient thickness and width to protect the part mechanically 
 and effectually to prevent the access of any microbes from the sur- 
 rounding skin or from the fingers of the patient accidentally inserted 
 beneath the edges of the dressing. This dressing is then held in 
 place by strips of adhesive plaster, with suitable bandages, splints, 
 etc., as required. If a tube or a wick of gauze has been employed for 
 drainage, the dressings are to be so arranged that the discharges 
 will be conducted into the dressings without soiling the surface of 
 the wound; this is accomplished by carrying the drain through slits 
 4n the dressing, and surrounding its outer end with sufficient crumpled 
 gauze to absorb the anticipated discharge; and carefully protecting 
 this superficial dressing from infection by sterile absorbent cotton 
 or more gauze, the entire dressing being suitably bandaged in place. 
 In aseptic incised wounds the drain, along with the superficial dressing, 
 may be removed at the end of twenty-four or forty-eight hours, 
 without disturbing the deep dressing. In infected wounds the drains 
 must remain until their tract is lined with granulations (four to six 
 days) converting it into a sinus, which is to be treated according 
 to the principles already discussed (p. 52) if it does not close spon- 
 taneously. Non-absorbable sutures are to be removed from the 
 sixth to the tenth day, and in the case of aseptic incised wounds the 
 dressing need not be changed until this time has elapsed. In small 
 wounds of the face superficial sutures occasionally may be removed 
 as early as the fourth day, but in the case of a larger wound, and 
 especially in the case of deep or relaxation sutures, it is unsafe to 
 remove them in less than a week or ten days. If a suture is found 
 at the first dressing to be cutting out, it should be removed, trusting 
 to the neighboring stitches to maintain the lips of the wound in 
 apposition; and frequently it is safer to remove only alternate stitches 
 at the first dressing, and leave the others a day or so longer, or to 
 support the wound with strips of sterile adhesive plaster applied at 
 right angles to its surface. 
 
LACERATED WOUNDS 
 
 \iu 
 
 Lacerated and Contused Wounds.- Lacerated and contused wounds 
 may \)v coiisidrrcd toj^ctlicr, as they are j)r()dueed by the same acci- 
 dents, and usually coexist. In lacerated wounds the edges are torn, 
 jagged, and irregular, not sharply cut as in the case of incised wounds; 
 in contused wounds the lips of the wound and the surrounding parts 
 are bruised and more or less devitalized by the original injury. Blows 
 by blunt weapons (clul)S, stones, etc.), and machinery and railroad 
 accidents are the principal causes of contused and lacerated wounds; 
 owing to the manner of their production they are almost invariably 
 infected, from bacteria on the patient's skin, his clothing, or on the 
 vulnerating weapon. Earth, machine oil, cinders, and other foreign 
 matter frequently are carried into the depths of the wound. Gunshot 
 wounds, forming a special variety of contused wounds are considered 
 in Chapter VII. 
 
 Symptoms. — The pain of contused and lacerated wounds is less sharp 
 and more aching than in the case of incised wounds; hemorrhage is 
 less, because the vessels are twisted and torn off rather than cleanly 
 severed; and gaping is often much less than the extent of the injury 
 would lead one to expect. Shock is often severe, and in case of crush 
 or avulsion of a limb maj' 
 cause death immediately 
 or so soon that no time 
 is afforded for local reac- 
 tion. This reaction in the 
 wounded parts frequenth' 
 extends to the stage of sup- 
 puration, and the tissues 
 are so much devitalized 
 that more or less sloughing 
 is the rule. 
 
 Treatment. — In addition 
 to combating shock and 
 checking hemorrhage, the 
 surgeon must pay particu- 
 lar attention to cleansing 
 the wound. Some of these 
 injuries are so severe that 
 nothing less than amputa- 
 tion will save life (p. 192). 
 But in lacerated wounds 
 or crushes of the hands, 
 much may be done without 
 amputation, by excision of 
 pulpefied tissue and splinters of bone, and by accurate suture of 
 divided tendons, etc. (Figs. 118, 119). Occasionally a completely 
 severed finger tip will grow in place if carefully sutured. General 
 anesthesia often is indicated to allow the necessary treatment to be 
 carried out. The object should be to make the wound approach 
 
 Fig. 118. — Compound fracture of metacarpals, 
 by circular saw injury. Excision of heads of meta- 
 carpals, and suture of tendons. Episcopal Hospital. 
 
 Fig. 119. — Same patient as Fig. 118. Earns $3.50 
 a day, working as carpenter. 
 
168 
 
 INJURIES AND THEIR EFFECTS 
 
 ill character as nearly as possible to an aseptic incised wound. The 
 woniid, itself, is first packed with sterile gauze. Then the surround- 
 ing skin should be painted with 3 per cent, iodin solution, and if 
 it is hairy it may be soaped and shaved after the iodin has become 
 thoroughly dry. If it is not hairy it is sufficient to apply a second 
 coat of the iodin solution after the first has dried. Then foreign 
 bodies are to be removed from the face of the wound, slitting up 
 pockets and crannies among the muscles and layers of fascia if neces- 
 sary to extract bits of clothing, coal dust, and other foreign bodies. 
 In some cases the filthy structures have to be cut bodily away. After 
 the wound has been thus mechanically cleansed, it should be treated 
 
 antiseptically, being swabbed out with 
 gauze soaked in iodin solution. I have 
 entirely abandoned the use of cor- 
 rosive sublimate and carbolic acid in 
 such cases, as I find strict adherence 
 to the iodin technique secures better 
 healing. Hydrogen peroxide is an- 
 other efficient antiseptic; it may be 
 applied after the iodin, but more 
 than one thorough application tends 
 to delay healing. In all cases the 
 cleansing should be done with gen- 
 tleness, it being an excellent maxim 
 of Sir James Paget's that "wounds 
 should not be scrubbed, even with 
 sponges." In spite of the utmost 
 care it is not always possible to en- 
 sure freedom from infection in these 
 wounds, so it is always best to drain 
 them, using only sufficient sutures 
 to hold the tissues in apposition at 
 the extremities of the wound. Iiiter- 
 rupted sutures always are to be pre- 
 ferred to continuous, in infected 
 wounds, since one or more can be 
 removed at any time to relie^'e ten- 
 sion, without destroying the entire 
 suture line. Instead of aseptic gauze it is better to use an antiseptic 
 dressing, especially of gauze soaked in equal parts of alcohol and 
 corrosive sublimate. In extensive wounds, where sloughing is feared, 
 it is well to pour alcohol over the dressings every few hours, so as 
 to keep them moist. Constant irrigation with antiseptic solutions 
 is often of great value (Fig. 120). If no undue rise of temperature 
 or local pain indicates excessive reaction the wound need not be 
 inspected until the third or fourth day; and if then the surgeon finds 
 evidence of damming up of secretions, abscess formation, or beginning 
 cellulitis, he should not hesitate to remove as many sutures as 
 
 Fig. 120. — Constant irrigation 
 for, crushes, contused and lacerated 
 wounds, etc. ^The solution drips over 
 the injured part by gauze syphonage. 
 Episcopal Hospital. 
 
PUNCTURED WOUNDS 
 
 169 
 
 rc(iiiisitc (all, if necessary), and pack the wouikI lightly with anti- 
 sej)tie gauze, using drainage tubes as indicated. In such cases the 
 wound gradually becomes converted into an idccr, and should be 
 treati'd accordingly. 
 
 Punctured Wounds. I'nnctnrcd wounds, as the term indicates, 
 are those prodncetl by pointed instruments, and their imjjortance 
 arises from the fact that infection (not rarely tetanus) is frequent, 
 as no free drainage exists; and because injury to deej) structures 
 (viscera, joints, nerv(>s, etc.), may pass uni)ercei\ed at first. In 
 ordinary practice punctured wounds are produced most often by 
 needles, nails, hat pins, splinters, umbrella tii)s, etc. If a needle 
 remains in place, with part of the shaft projecting from the wound, 
 it should be extracted, and unless known to be serioush' infected, 
 
 Figs. 121 and 122. — Skiagraphs to localize needle in palm of hand. 
 
 it is sufficient to cleanse the surrounding skin and apply an aseptic 
 dressing. In a patient at the Episcopal Hospital a hat pin which 
 punctured the chest produced no symptoms of any kind, though 
 from the depth and direction of the wound it is certain that the 
 liver, diaphragm, and lung were all traversed. If the point has broken 
 off and is completely buried in the tissues, an immediate attempt to 
 extract it should be made if its position can be detected by palpation; 
 if no clue as to its location exists attempt at extraction should not 
 be made until it has been accurately located by the use of the .r-rays, 
 two exposures in planes at right angles to each other being made 
 (Figs. 121 and 122). The incision, for which local anesthesia some- 
 times is sufficient, should be made obliquely to the course of the 
 needle, being thus more apt to strike it than if made parallel. A 
 
170 INJURIES AND THEIR EFFECTS 
 
 needle buried in the palm is best exposed by turin'nfi; uj^ a flap of 
 skin. If a large joint has been punctured, the part should be immo- 
 l)ilized, the patient being kept in bed if necessary. In wounds from 
 splinters and rusty nails the danger of tetanus developing is greater; 
 accordingly the ])uncture should be slit up, to ensure the removal of 
 all parts of the splinter, and to allow the application of antiseptics 
 to all parts of the wound. 
 
 Stab wounds occasionally are seen in cWW practice; they partake 
 of the nature of both incised and punctured wounds, and like the 
 latter are of interest chiefly from the implication of joints, internal 
 organs, bloodvessels, nerves, etc. Their treatment is considered 
 in the chapter dealing with the surgery of these structures. Bayonet 
 wounds are seldom seen nowadays, even in military surgery. In 
 battles with Indians and other uncivilized tribes arrow wounds are 
 sometimes encountered. The arrow-head is very easily detached 
 from the shaft, and reckless attempts to extract the weapon frequently 
 result in the head breaking ofY and remaining in the tissues as a foreign 
 body. Sometimes it is better to push the arrow on and extract it 
 through the counterpuncture. Indian arrows' were frequently 
 poisoned with rattlesnake venom or with earth containing tetanus 
 germs, and Schell found it a universal custom to dip the points in 
 blood which was allowed to dry on them; but such practices are 
 rare at the present day. 
 
 Tooth wounds, especially those due to human bites, are apt to be 
 severely infected. Dog bites are less dangerous than those of cats, 
 rats, and other domestic animals. Monkey and parrot bites are not 
 very rare. I have treated a case of mole bite. 
 
 Poisoned Wounds. — Under this heading it is convenient to consider 
 snake bites and insect-stings. The latter are seldom serious in this 
 part of the country, but in the tropics are sometimes fatal. The 
 lesion consists in a localized, occasionally a spreading cellulitis, 
 which is treated by evaporating and antiseptic lotions. The pain 
 of stings is quickly allayed l)y plastering the bite with liquid mud, 
 which should be washed off so soon as antiseptics are available; 
 aqua ammonise also relieves the pain and neutralizes the acid poison, 
 
 S7ial-e Bites. — Snakes (ophidia) are divided into two main classes, 
 the Colubrines, mostly harmless, and the Viperines, usually poisonous 
 (thauatophidia — death-suakes). To know whether the injury is from 
 a harmless or a poisonous snake, the bite should be examined: "If 
 the snake is harmless, two uniform rows of tooth marks will be found; 
 if there are two or more distinct fang-marks, with or without tooth- 
 marks, the snake is poisonous" (Fig. 123) (Mason, 1907). The 
 venom is contained in a sac at the base of the hollow fang, which is 
 on the upper jaw; this sac is compressed by the muscles which close 
 the jaws, and the virus is squirted through the hollow fang much 
 as through a hypodermic needle. Repeated biting soon empties 
 the poison sac, and the snake is then comparatively harmless until 
 more virus has been secreted. 
 
POISONED WOUNDS 171 
 
 The most iniportaiit coiistituciits of snake venom are a glol)uliii 
 aixl a peptone. Tlie former destroys the coagulability of the l)loo(l, 
 and pnxhiees moleeiilar changes in the vessel walls; this accounts 
 for the extra\asation and hemorrhages (subcutaneous, gastro- 
 intestinal, renal), which are characteristic of snake poisoning. The 
 j)eptone produces locally "rapid 
 edema. i)utrefaction, and 
 
 sloughing without extravasa- / / \ •. • .• "■ * 
 
 tion; constitutionally, it in- / : •. ". • .' '; 
 
 creases blood-i)ressure, acceler- I '■ : • '•[ • . . • 
 
 ates the respiration, and often ; ". ;" : •. : \ '• 
 
 causes convulsions." (Mason, • ". • •. : \ \ 
 
 1907.) In rattlesnake bites, • : : ■ • ; • ; 
 
 almost the only kind seen in • \ .• "•. • ; 
 
 this country, death occurs in • • ' ' 
 
 from 12 to 25 per cent, of cases, Fiq. 123.— Tooth marks made by snake 
 
 USUallv within twenty-four to bites: on the left a harmless snake; fang- 
 
 , . "^ . , TA ii i> marks in the centre and on the right indi- 
 
 thirty-SlX hours. Death irom cate a poisonous snake. 
 
 cobra bites, which are frequent 
 
 in India, and not very rare in the PhiUppines, occurs usually in a few 
 hours. Bites of copper-heads and moccasins are not so fatal, though 
 amputation may be required for sloughing, or septicemia may kill 
 at a later date. 
 
 Treatment consists, locally, in the immediate application of a 
 ligature or tourniquet around the limb above the wound, and in 
 suction of the punctures by the mouth, or by cupping glasses when 
 available. The venom is not poisonous when taken by mouth, if 
 the stomach is full; but it should of course be spat out. Free incisions 
 will make suction more effective. Amputation or excision of an 
 unimportant part may be done. The ligature should be used inter- 
 mittently, admitting only small doses of the venom into the circula- 
 tion at one time; and when the wound is far enough from the trunk 
 to make it possible, it is well to apply a high and a low ligature 
 alternately. Mason also recommends that the limb be bandaged 
 from its two extremities toward the wound, so as to squeeze out all 
 the venon possible. The best local applications after free incision 
 are oxidizing agents, such as peroxide of hydrogen, or 1 per cent, 
 solutions of potassium permanganate or chromic acid. The actual 
 cautery (hot coals, burning gun-powder) should be employed if these 
 remedies are not at hand. Local treatment should be prompt, as it 
 is probably useless after the lapse of half an hour. Constitutionally 
 alcoholic stimulants are indicated, being pushed to the point just 
 short of intoxication. Strychnin is considered valuable. Calmette's 
 serum (antivenene) should always be employed when available; 
 hypodermic injections of 10 to 20 c.c. of the stronger serum are 
 given as soon as possible. Gastric lavage and catharsis are indicated 
 to remove the venom excreted into the gastro-intestinal tract. Hope 
 should not be abandoned too soon, some remarkable recoveries being 
 recorded after the prolonged use of artificial respiration. 
 
172 INJURIES AND THEIR EFFECTS 
 
 GENERAL EFFECTS OF INJURIES. 
 
 Shock. — The immediate constitutional effect of injury is named 
 shock. A se^'e^e grade of sliock is called coUapse. Altliough no \ery 
 accurate knowledge of the pathogenesis of shock has yet ))een o})tained, 
 in spite of the elaborate experimental investigations of Crile (1899), 
 and others, it is certain that its most important features are due to 
 interference with the vaso-motor mechanism, resulting in marked 
 jail of hlood-y res sure. The action on the vaso-motor centre takes 
 place through the nerves supplying the injured part, and injuries 
 of regions endowed with more highly specialized nerves are more apt 
 to produce shock than injuries of other parts. Severe, even fatal, 
 shock occasionally follows injuries accompanied by insignificant 
 traumatism to the body tissues. Shock is especially apt to occur 
 from injuries of the larynx, and of the viscera, particularly those of 
 the upper abdomen, involving the splanchnic, and those of the thorax 
 involving the cardiac plexuses. Injuries of the genitalia are frequently 
 accompanied b}' marked shock, when the nerves of the spermatic 
 cord are bruised or injured. Extensive burns and scalds, affecting 
 immense numbers of peripheral nerve endings, are followed by marked 
 shock. Lacerated and contused wounds, gunshot wounds, mangling 
 injuries, and crushes are often accompanied by an extraordinary 
 degree of shock. Henderson (1908) has proposed the theory that 
 shock is due chiefly to loss of the carbon dioxide constituent of the 
 blood, a state to which he applies the term acapnia; and as carbon 
 dioxide is a W'cU known stimulant of the pressor mechanism of the 
 vaso-motor system, causing rise of blood-pressure, it is not improbable 
 that the shock which follows eventration of the intestines in certain 
 operations may be partly accounted for in this way. 
 
 Predisposing Causes. — General debility, extreme youth and age, 
 and organic disease of the heart, kidneys, or other viscera, are among 
 the predisposing causes. Exposure and chilling of the body surface, 
 if prolonged, will increase shock. Hemorrhage, by directly affecting 
 the patient's vitality, and lowering blood-pressure, is probably the 
 most important cause of all. Prolonged anesthetization acts in a 
 similar manner, chloroform causing lowering of blood-pressure from 
 the very first, ether only after long administration. 
 
 Symptoms. — The patient, if not stunned by the injury or suffering 
 from cerebral concussion, is conscious, his mind sometimes being 
 clear and alert, but more often semi-stuporous, as if the effort even to 
 think were exhausting. The face is pale, the lips ashen or slightly 
 blue; the entire body surface is pale, cold, and often clammy; the 
 temperature is subnormal (Fig. 124); the eyes are staring or half- 
 closed; there may be dimness of vision or actual blindness (from 
 retinal anemia); the pupils are dilated, and react sluggishly to light; 
 the respirations are shallow and rapid; the pulse is quick, fluttering, 
 weak and frequently uncountable. Incontinence of feces is frequent, 
 that of urine rare and usually portends a fatal issue. The patient 
 
SHOCK 
 
 173 
 
 DAY OF 
 MONTH 
 
 5 
 
 !- 1 'l> t 
 
 7 8 
 
 UK] 
 
 I 
 
 < '.)•.) 
 
 < 
 
 tii; 
 
 'Jo 
 
 
 J 
 
 ^1- 
 
 
 Fig. 124. — Shock and reac- 
 tion. Case of multiple frac- 
 tures; man, aged thirty years. 
 Episcopal Hospital. 
 
 lies inotioiilrss wluTcver plac<'<l. This torpid .sinf/r may last a few 
 minutes or several days. Death may oecur without reaction, in 
 spite of energetic treatment. If reaction occurs, the patient usually 
 sighs deeply, m()\'es his eyes and limbs voluntarily, and turns on 
 his side; vomiting is not an muisual sequel. Ueeo\ery may be aj)[)ar- 
 ently comi)lete in a few minutes, or may 
 occur gradually, especially when there is 
 some severe injury present. When reaction 
 occurs, it may be excessive, the ])atient be- 
 coming mildly delirious, and exhibiting the 
 condition described by Travers (1827) as 
 prostration with excitement (erethistic shock). 
 This condition, which occasionally develops 
 immediately after the injury, the torpid stage 
 being extremely short or altogether absent, 
 may pass into true traumatic deliri^im, an 
 affection probably due to some form of 
 toxemia. The patient is restless, talkative, 
 with bright, roving eyes and incessant action ; 
 he is really weak, though seemingly strong, 
 
 and is liable to collapse at any time. He is pursued by frightful 
 hallucinations, often acting over and over again in his delirium the 
 drama of his injury. Traumatic delirium should always be regarded 
 as a dangerous complication, being unusually serious when develop- 
 ing immediately after the accident. 
 
 After death from shock there may be found no lesions sufficient 
 to have caused death. In such cases death probably has occurred 
 from inhibition of the heart's action (collapse.) Usually, however, 
 the venous system is found to be filled with blood, the capillaries 
 and arteries being comparatively empty, and the great bulk of the 
 blood being contained in the portal system of veins and the vena 
 ca\'a : it is as if the patient had bled to death intravenously. Evidently 
 the heart has ceased to act because no blood was supplied for it to 
 contract upon, the coronary as well as the systemic arteries being 
 thus deprived of blood. 
 
 Under the name of secondary or insidious shock has long been 
 described a change, almost invariably fatal, usually occurring a 
 day or so after apparent recovery from the primary shock of an 
 injury or operation. At autopsy the right heart is found distended 
 with clots, which may invade the pulmonary arteries, constituting 
 pulmonary embolism (p. 178). It is probable that most such cases 
 are caused by a low grade of sepsis. 
 
 Diagnosis. — To differentiate shock from internal hemorrhage is 
 frequently impossible until the physical signs of the effused blood 
 appear; moreover, in any case of extensive hemorrhage, shock will 
 be present also. Syncope occurs without history of injury, the patient 
 becoming unconscious, and possibly being subject to fainting fits. 
 Psychical shock (fright) should not be mistaken for surgical shock; 
 
174 INJURIES AND THEIR EFFECTS 
 
 it may result in death in the absence of all injury, especially in cardiac 
 patients, but usually the mental trepidation soon passes off, having 
 caused no more serious disturbance than a sinking feeling in the 
 l)recordium, slight qualmishness, and a temporarily accelerated 
 pulse. Erethistic shock and traumatic delirium are to be distinguished 
 from delirium tremens and mania a potu. In these a history of chronic 
 alcoholism usually can be obtained, and the delirium is somewhat 
 different in character: in delirium tremens which may be regarded 
 as the first stage of the affection, the patient is fearful and shrinking, 
 the delirium is muttering, the hallucinations usually relate to insects, 
 reptiles, etc., and the trembling of the hands is characteristic; in 
 mania a potu, the second stage, he is violent, shouting, cursing and 
 singing, with no fear of man or devil, breaking loose from the bed, 
 attempting to climb out of the window, and having no sensations 
 of the pains caused himself, grinding his broken bones together as 
 if they were cobble-stones (Hunt, 1881), and sometimes wilfully 
 mutilating his person. Yet as alcoholics are prone to severe injury, 
 and therefore to shock, it is frequently impossible to say whether 
 the ensuing delirium is alcoholic or purely traumatic. The delirium of 
 uremic conditions (Chapter XXV) adds another confusing factor which 
 is often present in injured alcoholics and others with diseased kidneys. 
 
 Prevention of Shock. — General anesthesia does not prevent shock. 
 Ether is a cardiac stimulant, and when first administered by inhalation 
 or hypodermically, will increase the force of the heart beat, and in 
 this way may make the shock less than it would have been otherwise ; 
 but if long continued, the blood-pressure falls; and shock is increased. 
 Unconsciousness, however, almost invariably diminishes the shock 
 of an operation. The peripheral nerve trunks may be blocked by 
 injecting them with cocain, thus cutting off impulses of all kinds 
 which might reach the vaso-motor centre (anoci-association, p. 148); 
 in this way operative shock may be so prevented, that, as Crile says, 
 after cocainizing the nerve trunks and ligating the main vessels, 
 an amputation may be done with no more effect on the patient than 
 would be produced by cutting the sleeve oft' his coat. The hypodermic 
 use of atropin is valuable in two ways: it causes a rise of blood- 
 pressure by central action, and by paralyzing the inhibitory fibres 
 of the vagus prevents injurious impulses from reaching the heart 
 and producing collapse. Cocain hypodermically acts much in the 
 same way. Morphin is less efficient, and strychnin is practically 
 worthless except as a tonic administered for some days in advance of 
 operation. 
 
 During an operation the most important means of preventing 
 shock are control of bleeding, gentle manipulation, and maintenance 
 of bodily heat. Direct trauma to the tissues, especially nerves, 
 should be studiously avoided; direct division by the scalpel should 
 replace blunt dissection and tearing, dragging manipulations when- 
 ever possible. Mechanical means for maintaining blood-pressure 
 are discussed under Treatment. 
 
SHOCK ' 175 
 
 Treatment. 'V\w iiidications are to restore blood-pressure, ])revent 
 the loss of l)o(ly heat, and keep the patient alive (by artificial respira- 
 tion if necessary) until the remedies used have time to act. Bleeding 
 must be checked by pressure, elevation, tourniciuet, ligatures, etc.; 
 the patient's head should be lowered to allow the blood to flow into 
 the empty heart. Cover the patient warmly, and surround him with 
 hot water bottles, hot bricks, etc.; give him atropin, digitalis, or 
 adrenalin, hypodcnnically; encase his extremities in raw cotton, 
 and bandage them from the periphery toward the trunk (mitotrans- 
 fiision), thus forcing blood to the heart; perform artificial respiration 
 and apply massage to the heart by direct pressure over the precordium, 
 or transdiaphragmatically through an epigastric incision. Give 
 saline solution intra\'enously, and in severe cases, and where facilities 
 exist, do direct transfusion. Adrenalin may be added to the saline 
 solution (1 to 20,000). 
 
 Great care should be taken to be sure that serious symptoms 
 occurring during an operation are really due to shock, and not to 
 acute dilatation of the heart. In the latter condition, the measures 
 above detailed for driving more blood into the right heart wall only 
 make matters worse: the head should be kept high, and, if this does 
 not relieve, the patient should be bled, and in extreme cases the right 
 ventricle may be punctured. In any case, artificial respiration and 
 massage of the heart should be persisted in for fifteen or twenty 
 minutes. 
 
 In shock from inhibition, as in operations on the larynx and thoracic 
 organs, the most important measures are: the head-low posture 
 with artificial respiration and cardiac massage, both secured by 
 "rapid rhythmic pressure upon the thorax over the heart" (Crile), 
 with the tongue drawn well forward and upward, to open the larynx. 
 In shock due primarily to hemorrhage, the head-down posture, the 
 use of saline solution, and bandaging the extremities are of most 
 value. In the severest cases of shock, with cessation of respiration 
 and circulation (suspended animation), adrenalin should be added 
 to the saline solution, injecting 10 to 30 minims of a 1 to 1000 solu- 
 tion of adrenalin chloride, drop by drop, from a hypodermic syringe, 
 into the rubber tube through which the saline solution runs, the 
 entire amount being administered in about one minute (Crile). 
 Cardiac massage will force enough of the adrenalin saline solution 
 into the arterial system to raise the blood-pressure enough to sustain 
 the circulation. In conjunction with the other methods detailed 
 above, this may bring back the dead to life. If relapse follows tem- 
 porary improvement, more adrenalin should be used, as its effect 
 is evanescent. 
 
 Treatment of Traumatic Deliriimi and Delirium Tremens. — If the 
 patient is not too violent, attempts should be made to dilute the 
 toxins in the blood by the use of saline solution, by rectum, hypoder- 
 mically, or even intravenously. Lumbar puncture sometimes aborts 
 the disease. In any case the patient should be isolated, to avoid the 
 
176 INJURIES AND THEIR EFFECTS 
 
 mutually exciting effect of other patients. Catharsis will aid elimi- 
 nation of toxins. Sedatives and hypnotics should be freely employed, 
 especially veronal, and paraldehyde. Sleep should be obtained at 
 all hazards, but m()r])hin, hyoscin, chloral, and the bromides increase 
 the mortality, and arc much less effective than veronal and paralde- 
 hyde (Ranson and Scott, 1911). Measures must be taken to prevent 
 the patient from injuring himself, strapping him to the bed if necessary, 
 and never leaving him unguarded by a nurse or orderly strong enough 
 to control his actions. Liquid diet should be taken in moderation, 
 but the more water that can be absorbed the better. Ranson and 
 Scott urge the use of ergot (1 dram of fluidextract every four 
 hours) as preventative of cerebral edema and as a general circulatory 
 stimulant. No alcohol should be given to patients ^^'ith alcoholic 
 delirium; though Ranson and Scott urge its administration at least 
 in the first stage of the affection, all surgeons of large experience in 
 accident w^ards find that immediate and absolute icithdrawal of alcohol 
 from patients with delirium tremens both shortens the disease and 
 decreases the mortality. In traumatic delirium from burns, etc., 
 in which there is clear evidence that no element of delirium tremens 
 is present, but in which delirium is due chiefly to asthenia, the 
 moderate use of alcohol frequently hastens convalescence. 
 
 Causes of Death after Operation. — As operations always involve 
 the infliction of wounds, this seems a suitable place to consider the 
 causes of death after operation. Certain of these causes are more or 
 less avoidable; such are shock, hemorrhage, pneumonia, and sepsis. 
 Others usually seem unavoidable, especially myocarditis, embolism, 
 status lymphaticus, heat prostration, and conditions previously 
 present which the operation could not remove or which it has inevit- 
 ably made worse. Among the latter may be mentioned various forms 
 of sepsis (peritonitis, pyemia, etc.), curable only by removal of the 
 original focus and the institution of drainage, but which these meas- 
 ures, though judiciously and skilfully executed, nevertheless fail to 
 relieve; asthenia from preexisting shock or hemorrhage, death being 
 certain without operation, but a fighting chance of recovery existing 
 after prompt operation; and preexisting disease of the kidneys or 
 other organs when operation is undertaken as the only means of 
 cure. The conscientious surgeon will never, therefore, blithely assure 
 his patient that any operation is entirely devoid of risk, as these 
 calamitous deaths frequently occur when least expected. 
 
 Shock. — See p. 172. 
 
 Hemorrhage. — The importance of preventing loss of blood during 
 operations cannot be overestimated; and, fortunately, gross and 
 sudden hemorrhages usually can be prevented, for it is these which 
 are much more lethal than the slight ooze throughout the operation 
 which sometimes is unavoidable. But even though quite large 
 amounts of blood may be lost gradually without producing immediate 
 and noticeable effects, it is much better for the surgeon to go about 
 his work deliberately, clamping or tying bleeding vessels as he goes, 
 
CAUSES OF DEATH AFTER Ol'EHATIOS 177 
 
 than to try to hurry aloii^ and by liis very haste niakiiiji: less speed 
 from ha\iii<: continually to return and pick up vessels whieh niij^ht 
 have heen eau^dit with more ett'eet when first divided, and thus 
 subject his ])atient not only to the unnecessary if gradual loss of 
 blood, but also to a needlessly j)rolonged operation, and to unneces- 
 sary tissue traumatism from rej)eated sponging and search for the 
 bleeding points. 
 
 In addition to this primary hemorrhage which occurs at the time of 
 operation, surgeons recognize an intermediary, consecuti\e, or reac- 
 tionarii hemorrhage, which occurs after recovery from the anesthetic 
 or the shock of operation, due to the reestablishment of the normal 
 circulation and blood-pressure, causing bleeding from vessels which 
 escaped notice at the time of operation owing to their collapsed 
 condition; and a seeondarii hemorrhage, which occurs any time between 
 the occurrence of reaction and the ultimate healing of the wound. 
 Secondary hemorrhage is due usually to separation of ligatures 
 (1) from their having been insecurely applied at first; (2) to their 
 premature absorption; or (3) to ulceration of the vessel walls at the 
 site of ligation; occasionally it is due (4) to sloughing of a vessel at 
 another point in the wound. 
 
 The treatment of hemorrhage is discussed at p. 228. 
 
 Pneumonia. — Careful examination of the lungs should always be 
 made before undertaking any operation, especially under a general 
 anesthetic. If bronchitis or pneumonia already exists and the oper- 
 ation cannot possibly be postponed, as in the case of strangulated 
 hernia, local or spinal anesthesia should be employed. To prevent 
 the development of pulmonary complications, a general anesthetic 
 must be given with care, guarding against choking, secretion of mucus, 
 and inspiration of vomited particles; and pains must be taken not to 
 expose the patient to chilling, draughts, etc., either during operation 
 or while recovering from the anesthetic. After an operation, patients, 
 especially if aged, should not be kept flat on the back long, being 
 turned from side to side at suitable intervals to guard against the 
 development of hypostatic congestion; deep breathing should be 
 enjoined periodically; and they should be allowed to sit up or to 
 leave the bed so soon as the condition of the wound permits. 
 
 Sepsis. — In operations on previously aseptic structures, sepsis can 
 and should be prevented. Whenever it occurs under such circum- 
 stances, the surgeon should seriously endeavor to detect the fault 
 in his technique, in order that a similar calamity may not occur 
 again. In operations on already infected parts, it will not always 
 be possible to prevent infection from spreading further, or from 
 becoming more virulent even if still localized; but by strict adherence 
 to antiseptic methods, unfavorable results might be made much less 
 frecjuent than they are. 
 
 Myocarditis. — "Heart failure" usually is an una\oidabIe cause of 
 death; detection of the lesion before operation is frequently difficult, 
 and even skilled physicians occasionally err in estimating the ability 
 12 ' ' 
 
178 INJURIES AND THEIR EFFECTS 
 
 of an evidently diseased heart to withstand the strain of operation. 
 The choice of anesthetic, the position of the patient during operation, 
 avoidance of causes of cardiac collapse and of shock, the rapidity 
 and extent of the operation itself, all deserve to be considered more 
 attentively than usual in such patients. 
 
 Embolism. — Under the term "secondary or insidious shock" (p. 
 173 J was formerly described a condition which is now popularly 
 known as "pulmonary embolism." From some chemical change 
 (bacterial or aseptic) in the blood, it becomes more prone to clot, 
 and at various periods after operation, but usually not until con- 
 valescence seems assured, a portion of a thrombus, formed at or near 
 the seat of operation, is detached, is carried to the right heart, and 
 thence to the pulmonary arteries, where it may lodge; or, passing 
 through, may cause pulmonary infarction. The symptoms are sudden 
 dyspnea, cyanosis, precordial pain, collapse, and rapid, perhaps 
 immediate, death. Busch (1909) has recently studied twenty-two 
 deaths after operation, presenting symptoms usually ascribed to 
 pulmonary embolism : twelve of these patients died with great sudden- 
 ness, no preliminary symptoms of any kind existing; while in ten 
 death occurred at periods varying from ten minutes to three and 
 one-half hours after onset of the symptoms. These ten patients 
 all came to autopsy, and in only five was a pulmonary embolus or 
 infarction found, the five others having died from myocarditis. The 
 diagnosis, therefore, is not always easy. 
 
 Treatment. — The treatment is purely symptomatic, including 
 inhalations of ammonia, and the hypodermic use of atropin, oil of 
 camphor, etc. Trendelenburg (1908) has proposed arteriotomy of 
 the pulmonary artery, by opening the pericardium, with removal 
 of the clot; he adopted the operation in one case, his patient living 
 until the next day, while Siever's patient (1908) lived fifteen hours. 
 As death frequently occurs with great suddenness, giving no oppor- 
 tunity for treatment of any kind; and as in other cases recovery 
 under expectant treatment, though rare, is not unknown; and as the 
 diagnosis between myocarditis and embolism is often impossible, I 
 think Trendelenburg's operation should be regarded at present more 
 in the light of interesting surgical gymnastics than as a practice for 
 habitual employment. 
 
 Fat-embolism. — Fat-embolism occasionally occurs after injuries of 
 or operations on bones. The symptoms and treatment resemble 
 those of ordinary pulmonary embolism; lipuria is not pathogno- 
 monic, though suggestive, and it may exist in cases of simple fracture 
 without evidence of embolism. 
 
 Status Lymphaticus. — This term is used to describe a condition 
 in which there exists widespread enlargement of lymphoid tissue 
 in all portions of the body — naso-pharyngeal "adenoids," cervical 
 "adenitis," hypertrophy or hyperplasia of the bronchial and mesen- 
 teric lymph nodes, and of the thymus gland. It is most frequent 
 in rachitic children, and subjects of it are liable to sudden death at 
 
CAUSES OF DEATH AFTER OF E RAT 10 X 
 
 179 
 
 any time, even diirins natural sleep (Blumer, 1903). The true cause 
 of these deaths is not known, but is probably to be classed as an 
 "auto-intoxication;" death almost certainly is not due to acute 
 enlargement of the thymus gland causing asphyxia from pressure 
 on the trachea. Unfortunately the existence of the condition is 
 rarely if ever recognized until death occurs. Undoubtedly some 
 deaths charged to the anesthetic really are due to the status lymph- 
 aticus. Death may occur while the patient is under the anesthetic, 
 or, as is more often the case, a few hours later, with symptoms of 
 dyspnea, rapid, feeble pulse, high temperature, and restlessness, but 
 
 Fig. 125. — Case of severe knock-knee due to rachitis; death from "status lymphaticus" 
 five hours after double osteotomy. Orthopedic Hospital. 
 
 with no evidence of traumatic delirium. In the case of the patient 
 shown in Fig. 125, death occurred five hours after the completion 
 of a double osteotomy; and at autopsy no lesions could be found 
 other than diflPuse enlargement of the bronchial and mesenteric lymph 
 nodes. There was no evidence of pulmonary embolism, fatty or 
 other, and death was attributed to the status lymphaticus. 
 
 Heat Prostration. — Heat prostration occasionally causes a post- 
 operative death. The symptoms and treatment are the same as 
 for heat prostration in other patients. It is well to postpone all 
 operations but those of immediate necessity during the prevalence 
 of extremely hot weather. 
 
CHAPTER VII. 
 GUNSHOT WOUNDS. 
 
 Gunshot wounds are those produced by missiles projected by the 
 explosive action of gunpowder. The missiles include the various 
 projectiles from artillery {shell, solid-sliot, cannister, and shrapnel); 
 hullcfs from small-arms (muskets, rifles, revolvers); as well as small 
 shut from shotguns. Solid-shot and shells are directed rather against 
 defences than the soldiers on guard, and these rarely are injured 
 except by fragments of such large missiles. Shrapnel and cannister 
 are much alike, being composed of a collection of small missiles 
 within an iron casing; but cannister explodes as it is discharged from 
 the gun, while shrapnel contains an explosive in its centre, with a 
 time fuse, and is exploded only when the time-fuse is consumed. 
 Both shrapnel and cannister are used only at close range. The 
 injuries produced by all forms of artillery missiles are exceedingly 
 destructive, partaking of the nature of contused and lacerated wounds. 
 In naval warfare such wounds are much more frequent than those 
 from small-arms. Amputation frequently is required. 
 
 Bullet wounds comprise nearly 90 per cent, of those seen in war, 
 and form almost the only variety of gunshot wounds encountered 
 in civil life, with the exception of occasional wounds from small-shot 
 or from wadding out of blank cartridges. ^Musket balls (round) 
 are no longer used in civilized warfare, their place ha^•ing been taken 
 by conoidal bullets projected from rifled barrels (Fig. 126). The 
 rifling imparts to the missiles a rotatory motion, or spin, which in 
 the case of the modern ]Mauser bullet approximates 2500 revolutions 
 per second on its discharge, at which instant its velocity is nearly 
 2700 feet per second {initial velocity). The ]Mauser bullet now in use 
 in the U. S. Army is 0.30-calibre (/. e., 0.30 inch in diameter), and 1.08 
 inches long; it consists of a core of lead and tin composition inclosed 
 in a jacket of copper and nickel (Borden, 1913). The high velocity 
 imparted to the modern bullet tends to make its trajectory (line 
 of flight) more nearly horizontal, thus increasing the danger zone} 
 The rotary motion and high velocity, combined, tend to lessen the 
 bullet's dip, thus enabling it to strike more nearly end-on; while 
 both factors markedly increase its penetrating power. The range of 
 
 iWhen fired horizontally ("point blank") the danger zone embraces the entire 
 trajectory of the buUet, which under such circumstances is about 700 j-ards in 
 length; when aimed at a greater distance the shot is fired into the air, the trajectory 
 is a paralDohc curve, and the danger zone is removed to the area within which 
 the bullet is liable to strike earth. 
 
cuNsnoT wni'XDs 
 
 ISl 
 
 thr modern niilit;iry hiillct is fairly accuriitc up to one mile. i5ullets 
 may strike elsewhere first, \vouii(liii<i; the ])atieiit only !)>' ncoclid, 
 after heiiij;- deformed 1)\ the first iini)a(t; such wounds are more 
 apt to he laceratcil and contused. 
 
 Fig. 126.— Evolution of the iMiUct. 1. 
 3, 0.4.5-faIibr<- Springfield; 4, 0.3()-c:ilil)r< 
 natural size. (Bryant and Buck.) 
 
 old rounded musket t 
 jacketed Springfield, 
 
 2, Minie Inillet ; 
 ](■[ 190.-,. .Ml of 
 
 At close range, the modern military bullet has what is known as 
 an explosive effect; that is to say, any marked resistance causes its 
 energy to be transmitted into the surrounding tissues. The more 
 resistant the tissues, the more marked is the explosive effect. This 
 is particularly noticeable in bone: if the spongy, expanded epiphyses 
 are struck, there is little resistance offered and a grooved or tunnelled 
 wound will })e produced (Fig. 127) ; whereas if the hard brittle diaphysis 
 is struck the bone will be shattered (Fig. 128). Fluid-saturated or fluid- 
 containing organs offer extreme resistance to bullets, because of their 
 lack of compressibility; the brain, the liver, and the hollow viscera (if 
 distended with liquid or semi-solid food) afford notable examples of 
 this explosive action at close range. This destructive action is due to 
 the missile's high initial velocity. Larger missiles (as the old round 
 shot) with much lower velocity, even when almost spent, may ha\'e 
 an equally destructive action. These facts are conciseh' expressed 
 in the physical formula M = mv; that is, the momentum equals the 
 product of the mass by the velocity, and if either the mass (as in the 
 larger missiles) or the velocity (as in the modern military bullet) 
 be sufficiently great, the momentum of the projectile, and hence its 
 destructive action, will be correspondingly great. 
 
 The bullet wounds encountered in civil life (suicide, homicide, 
 etc.) as a rule are not produced by modern military bullets, but by 
 softer, unjacketed bullets (jNIinie or Springfield) of low velocity 
 (about 700 feet per second) ; the calibre varies from 0.22 to 0.40 or 
 0.45, but is usually large; and the wounds much more resemble those 
 seen during the War of the Rebellion. As in civil life the bullet is 
 softer, larger, and slower, it is more easily deflected and deformed, 
 and almost invariably lodges in the patient's body; the wound is less 
 clean cut, more lacerated and contused, than that produced by the 
 
182 
 
 GUNSHOT WOUNDS 
 
 military bullet; the bullet remains as a 
 foreign body; and infection is much more 
 frequent. In war it is very exceptional 
 for the bullet to lodge in the patient's 
 body; and owing to the greater velocity, 
 the direct impact, and the rectilinear 
 course of the bullet through the body, 
 and its subsequent absence from the 
 wound, infection is less usual. Unless 
 a large bloodvessel or important organ 
 IS wounded, death in war is seldom im- 
 mediate; but it appears to occur in a 
 larger proportion of cases since the intro- 
 duction of the modern bullet, largely 
 because of its penetrating power, which 
 causes it to cut cleanly through or to 
 groove large bloodvessels, instead of 
 rupturing or contusing them. The latter 
 result, commoner with the soft bullet, 
 favored clotting and prevented death 
 from hemorrhage on the field. 
 
 General Characterof Gunshot Wounds. 
 —As already noted, the wounds produced 
 by artillery missiles are very severe, a 
 limb being completely carried awav, the 
 head being blown off, or a large portion 
 
 Fig. 127.— Cancellous bone perforated by bullet 
 (After Helferich.) 
 
 Fig. 128. — Compact bone shat- 
 tered by bullet. (After Hel- 
 ferich.) 
 
Bi'LiJ'JT woi'xns 
 
 1S3 
 
 of tlu' trunk \m\v^ actiiiilly destroyed. In cixil life such injuries are 
 oeeasionally eneouiiterred in Mastini; accidents, e.\i)losions, etc.; tlie 
 wounds are severely lacerale(l and contused, and recjuire tiie usual 
 treatment for sucli lesions. As the skin is elastic, a slowly n)o\injf 
 cannon-i»all t're((nently lias j)ro(luced suhcutaneous injuries (fractures, 
 rupture of xcssels, etc.), without laceratinjj; the intef^uuient; such 
 injuries were formerly attril)uted to the "wind" of the hall. 
 
 Bullet womtdf are in the nature of jjunctured wounds, and either 
 pcncfnifr or perforate the body. If they merely penetrate, there is only 
 a wound oj entruuce;^ if they perforate there is 
 a wound of entrance and also one of exit (Fig. 
 120), except in very rare cases where the 
 bullet makes a circuit within the body and 
 emerjfes again by the wound of entrance. If 
 fired at close range (usually not over 3 feet) 
 there will be powder-marks around the wound 
 of entrance. The wound of exit is usually, 
 esi)ecially in civil life, larger than the wound 
 of entrance, and its margins may be some- 
 what everted. This is due to the bullet being 
 deformed after striking, to the reduction in its 
 velocity, to its carrying particles of flesh or 
 bone before it into and out of the wound, or 
 to it emerging sideways (no longer "end-on"). 
 The wound of entrance sometimes seems 
 smaller than the missile by which it was pro- 
 duced, from the elasticity of the skin. If two 
 bullets enter b>' the same wound, one may pass 
 through and the other lodge; or they may 
 emerge by the same or by difi'erent wounds; 
 and two bullets may enter by different 
 wounds and emerge by the same wound of 
 exit. One bullet may traverse successively 
 various parts of the body, making wounds of 
 entrance and exit in both lower or upper 
 limbs, or in a limb and the trunk, or if the 
 limb is acutely flexed, traversing the same 
 limb twice. The track of the bullet forms a 
 sinus which heals by the ordinary processes 
 
 of repair. The smaller the calibre of the bullet, the less likely is 
 sloughing to occur; wounds by bullets of 0.22 calibre frequently heal 
 without infection, even in civil life; those by bullets of 0.35 calibre or 
 over almost invariably suppurate throughout their extent. 
 
 Symptoms. — These are general and local. Shock is seldom marked 
 in modern warfare, unless a vital organ is wounded, or unless the 
 bullet has been fired at close range, w^ith explosive effect; in the heat 
 
 1 This may be within the mouth, or even within the anus or the external auditory 
 meatus, when it is readily overlooked. 
 
 Fig. 129. — 0.3S-calibre 
 bullet wound in right calf. 
 Wound of entrance on 
 outer side: wound of exit 
 on median side. Five days 
 after injury. Episcopal 
 Hospital. 
 
184 GUNSHOT WOUNDS 
 
 of battle, a soldier may be scarcely aware that he is wounded until 
 he feels the trickling blood. Traumatic delirium occasionally is 
 marked, sometimes occurrinji; at once, without any ii])])arent shock. 
 Pain rarely is great, usually being merely a stinging sensation, as 
 if from a smart blow with a whip or stick. Ilemurrhage seldom is 
 profuse, unless from the wound of a large bloodvessel; under such 
 circumstances it is likely that a large hematoma will form. Secondary 
 hemorrhage (p. 177) is liable to occur at any time until all sloughs 
 separate. 
 
 Prognosis. — In warfare there is one soldier killed for every four, 
 five, or six wounded ; and this proportion has been very little altered 
 by the changes in military equipment. A large proportion of gunshot 
 wounds, therefore, seems to be necessarily fatal; but in the remaining 
 cases the prognosis depends almost entirely upon the treatment. 
 By modern methods the death rate has been reduced to 5 or 10 per 
 cent. The bullet wounds of war are not seriously infected of them- 
 selves, and if kept clean the resistance of the patients usually is 
 sufficient to ensure a good result, at least as regards life. Injuries 
 of the trunk are more serious than those of the extremities, because 
 of damage to viscera; but they are also less frequent. Injuries to the 
 extremities involving bones, joints, or bloodvessles are more serious 
 than mere flesh wounds. The positions of the wounds of entrance and 
 exit frequently will enable the surgeon to exclude injury of important 
 structures. 
 
 Treatment. — In modern warfare the bullet seldom lodges, and 
 even if it does, it rarely causes immediate trouble; hence it is not 
 necessary to remove it. Every soldier is supplied with a "first-aid 
 packet," and is instructed to apply the sterile gauze dressing so as 
 to occlude the wounds of entrance and exit, fixing it in place with 
 the bandage which is attached. Only in case of active hemorrhage 
 is any operative treatment required on the battlefield; and if the 
 he;norrhage, profuse at first, has ceased spontaneously, it usually is 
 safer to apply a provisional tourniquet (Fig. Ml) and transport the 
 patient, who w\\\ be much shocked, to the field-hospital (at least 
 three miles from the front), than to undertake what may be a serious 
 operation in unfavorable surroundings. Here, or preferably at the 
 military hospital at the nearest base, the injuries to nerves, tendons, 
 bones, etc., should receive suitable treatment. 
 
 In civil life the bullet generally lodges, or is arrested by the skin 
 on the opposite- side of the body; and from its large calibre and the 
 nature of the wound it makes, frequently requires removal; and this 
 is best accomplished within twenty-four hours or not until the inflam- 
 mation has subsided. A bullet is best detected by the .r-rays; it 
 may be accurately located by two exposures made at right angles to 
 each other, with some suitable landmark as a guide (Figs. 130 and 131). 
 If the .T-rays are not available, the track of the bullet may be probed 
 (except in wounds of the abdomen), after thorough antiseptic prepara- 
 tion. A porcelain-tipped probe (Fig. 132), first employed by Xelaton 
 
SMALL SHOT WOl'XDS 
 
 185 
 
 ii) the casi" of tlic (clcltnitfil (umutuI Garibaldi (18()2), will retain the 
 marks ot" a soft lead hiillet, e\eii after the hlood has heeii rinsed ofV 
 ill water; hut it is of little \ise in detecting- the modern hard jacketed 
 bullets. The stem of a elay i)ii)C was used by IIei<i;hway during' the 
 Mexican War (184S). Tactile sensation, transmitted through an ordin- 
 ary probe, may enable the surgeon to detect the bullet's presence. The 
 
 Fig. 130. — Bullet lodged in knee-joint, 
 localized by skiagraphy; compare Figs. 
 1.31, 134, 135. Episcopal Hospital. 
 
 Fig. 131. — Lateral view (skiagraph) 
 of bullet lodged in knee-joint. Epis- 
 copal Hospital. 
 
 bullet may be removed by bullet-forceps (Fig. 132) introduced through 
 the nearest aperture, or by a counter-incision. If the bullet is situated 
 at all deeply, in the flesh\' part of a limb, it usually is necessary to 
 dissect down upon it; under such circumstances the finger is the best 
 probe. The incision should be closed with buried and superficial 
 sutures, and drainage should be provided for at least twenty-four 
 hours. 
 
 Fig. 132. — 1, Nelaton's porcelain tipped probe; 2, bullet-forceps. 
 
 Small-shot Wounds. — If fired at close range, small-shot produces 
 great damage, the wounds resembling those caused by artillery 
 projectiles. I have seen all the soft tissues on the front of the lower 
 forearm carried away in bulk, necessitating amputation, even though 
 the bones were not fractured. Fingers, toes, and parts of the hand 
 or foot are frequently blown off. If at longer range, the shot scatters, 
 there is no powder-burn, and comparatively little damage may be 
 
186 
 
 GUNSHOT WOUNDS 
 
 done, particularly in the case of birdsliot. Of course if the eye be 
 struck, or an important nerve or bloodvessel injured, the consec|uences 
 may be very serious even from the impact of one or two shot. It is a 
 tedious job to extract all these small shot, and it is seldom necessary 
 to do so. If the part be treated as for a contused wound it usually 
 does well. 
 
 Wounds from blank cartridges scarcely require separate mention. 
 They occur in this country chiefly about the Fourth of July. I have 
 not been- able to convince myself that they are more liable to be 
 followed by the development of tetanus, if properly treated, than 
 other punctured and contused wounds. If the wadding has lodged, 
 it should be extracted, entirely devitalized tissue should be cut away, 
 the raw surfaces swabbed with solution of iodin (3 per cent.), and the 
 wound dressed antiseptically. 
 
 GUNSHOT WOUNDS OF SPECIAL STRUCTURES AND REGIONS. 
 
 Bloodvessels. — For primary hemorrhage, the same rules apply here 
 as elsew'here (p. 230). Usually the bloodvessels are more or less 
 contused by bullet Avounds in civil life, and thrombosis is sufficient 
 to prevent free bleeding; if a bloodvessel is struck by a military 
 bullet, howcA'cr, it is cut across or grooved, and hemorrhage is profuse. 
 Secondary hemorrhage is not unusual, especially if the wound becomes 
 infected; its treatment is described at p. 232. False aneurysm (p. 233), 
 or arterio-venous aneurysms (p. 235) are sometimes remote conse- 
 quences of gunshot wounds of arteries and veins. 
 
 Nerves, Tendons. — In warfare these are 
 not deflected by the bullet, but are cut 
 through. Nerves may be seriously injured 
 also by being grazed by a bullet, causing 
 what the Germans call an " Frsschhiitter- 
 ung" of the nerve which England's great 
 lexicographer might have translated by the 
 term "tremef action." Severed nerves and 
 tendons should be sutured as soon as proper 
 operative technique can be secured. 
 
 Bones. — Gunshot fractures require the 
 same treatment as other compound frac- 
 tures (p. 312). The shafts are usually much 
 splintered (Fig. 128), unless injured by a 
 nearly spent bullet, which is then deformed 
 on striking (Fig. 133); fractures of the 
 epiphyses are less serious, unless the joint 
 is wounded. 
 
 Joints.^Gunshot wounds of joints were formerly exceedingly 
 fatal; in the Rebellion the mortality varied from 9 per cent., for the 
 elbow, to 84 per cent, for the hip. In the Turko-Russian War (1877) 
 von Bergmann found that death occurred in 95 per cent, of gunshot 
 
 Fig. 133.— Soft bullet de- 
 formed (mushroomed) by strik- 
 ing bone end-on. From a 
 patient in the Episcopal Hos- 
 pital. 
 
GUNSHOT worNns of special structures and recions 187 
 
 wounds of tlie kiioc-joint treated hy accepted methods; lie tlicrefore 
 "selectetl fifteen of the most serious cases of gunshot wound of tiie 
 knee, . . . Jind trciitcd thi'm by immohih'/ation iind occhisive 
 dressin<;s. In these casi-s, recoxcry with mo\;d)h> joints resnhed with 
 hut a singh' ex(('])tion, where am])utation liad to he <h)ne and (k-ath 
 followed" (Borden, 1907). Since that time modern military surj^cons 
 have followed von Berjjmann's example, treating all joint injuries, 
 except those re^iuiring inunediate amputation, by aseptic occlusion 
 anil innnobilization. In the Spanish-American ^Var, there were forty- 
 three cases of injury to the larger joints, and in only two was operation 
 reipiired — amputation in both cases, with one death, a total mortality 
 of 2.0 per cent.; in the Chinese-Japanese War there were fort\-seven 
 injuries, with five deaths, a mortality of 10.0 per cent. 
 
 Fig. 134. — Result of artlirotoniy and Fig. 1.35. — Result of arthrotoniy and 
 
 extraction of bullet from knee-joint; extraction of bullet from knee-joint. Same 
 recent accident. Episcopal Hospital. patient as Figs. 130, 131, and 134. Epis- 
 
 copal Hospital. 
 
 In warfare the bullet seldom lodges, and even in civil life it is not 
 so apt to lodge in the joint as in the neighboring bones or soft parts; 
 hence there is no indication to open the joint for its removal. Its 
 location can be determined by skiagraphy, and it may be extracted 
 at a later date if productive of symptoms. Sometimes a bullet has 
 ulcerated into the joint after lying perdu for many years in the end 
 of one of the articulating bones; under such circumstances it produces 
 the symptoms of a foreign body or loose cartilage in the joint. Quenu 
 (1910) has collected twelve instances in which a bullet was removed 
 from the knee-joint (three immediate, and nine tardy operations): 
 and I have had under my own care the patient represented in 
 
\RR 
 
 GUNSHOT WOrXDS 
 
 Figs. i:^(). i;;i. i:;4, ]:]d. In E. II. Ochsner's patient (1910) a Inillct was 
 successfully removed from the hip-joint ten years after the injury. 
 
 Head. — Gunshot injuries of the head are most serious when 
 fracturing the skull or injuring the brain. The general mortality 
 from gunshot fractures of the skull has not been materially reduced 
 in modern wars, still being nearer 60 than 50 per cent. At close range 
 the explosive effect is present, and death is instant (Fig. 136). Even at 
 long range the penetrating power of the modern bullet renders injury 
 of the brain much more frequent than formerly; and the bullet seldom 
 lodges. In civil life these injuries frequently are the result of suicidal 
 attempts, the wound of entrance being within the mouth, in the right 
 temple, or in the forehead. Even if the brain is injured there may 
 
 Fig. 136. — Skull, showing explosive effect of bullet fired at close range; a and b, 
 wounds of entrance and exit. (Von Bergmann.) 
 
 be no localizing symptoms (p. 583). The only indications for operative 
 treatment, which in no case should be attempted until complete 
 asepsis is assured, are (1) to disinfect the wound of entrance; (2) to 
 arrest hemorrhage; (3) to repair damage to the cranium; and (4) to 
 remove a lodged missile if it is producing symptoms. If the wound 
 of entrance is small, not liable to cause further trouble from infection; 
 if the fracture of the skull is a mere puncture, without comminution 
 or fissuring; if there are no symptoms of internal hemorrhage or com- 
 pression of the brain; and if the patient does not grow progressively 
 worse, no operation should be done. If the wound of entrance is 
 lacerated, contused, filthy, and splintering of the skull is evident, 
 operation should be undertaken as in any case of fracture of the skull 
 
GUNSHOT WOIWDS OF SrEOIAL STRUCTUJiKS AM) U/'XIIOXS ISO 
 
 whctlier tlierc are (■(Tel)ral syinj)t()ni.s or not. riidi-r sucli circum- 
 stances I o])erate(i (February, 1909) successfully on a patient in the 
 Kpiscopal Hospital, with a suicidal wound in the middle of liis fore- 
 head, renio\in^f fraj;ments of the hullet and of hone from the superior 
 longitudinal siiuis. If undiT such circumstances the dura is found to 
 be wounded it should l)e incised, and drainage provided for; but no 
 attem])t should be made to remove the bullet from the substance of 
 the brain unless it is causing sym])toms. In cases where it is belie\"cd 
 the liullet is producing symj)toms (for these ma\' be due to hemorrliage 
 and extravasation, not to the bullet), its location should be determined 
 by skiagraphy, and its removal attempted by the nearest approach: 
 sometimes the original track may be followed, at other times the 
 opposite side of the skull must be opened. In following the orginal 
 track, a heavy probe with a large bulbous end should be selected, 
 and the patient should be so placed that the probe will sink by its 
 own weight verticall\- into the bullet's track. Then by passing a 
 bullet -forceps along the probe as a guide, it may be possible to extract 
 the bullet. 
 
 Spine. — Gunshot wounds of the spine have increa.sed in severity 
 in recent wars; the mortality in the Spanish-American and Philippine 
 campaigns was (iC) i)er cent. (Borden, 1907). Nearly every case of 
 injury to the spine is now a compound fracture: wounds of the arches 
 are comminuted, but a bullet may perforate the body of a vertebra 
 without much damage to the bone. The cord is frequently cut in 
 two; even contusion of the cord, or "Erschiitterung," may result in 
 complete transverse lesion. In civil life, the slowly moving bullet 
 usually is arrested by the spine, and fracture without injury of the 
 cord is the rule. In military practice, immediate operation is not 
 indicated. The symptoms, treatment, etc., of injuries of the spine 
 in civil life are considered at p. 599. 
 
 Thorax. — Gunshot wounds of the thorax rarely are serious unless 
 they penetrate and wound the viscera. Instant or rapid death fre- 
 quently follows injury of the heart or great vessels; but injury to the 
 lung at some peripheral i)oint may be productive of no immediately 
 serious symptoms. P^specially is this so in the case of bullets of small 
 calibre striking at more than 000 yards. In warfare the bullet seldom 
 lodges; in civil life it nearly invariably is arrested, frequently being 
 found beneath the skin on the opposite side of the body. It is impor- 
 tant to look for it carefully beneath the skin, if there is no wound of 
 exit, so as to determine if possible its course through the thorax. A 
 bullet may seem to traverse the thorax, and yet wound no viscus; 
 while a wound which does not penetrate far may cause alarming 
 symptoms from hemorrhage from the internal mammary or an inter- 
 co.stal artery. 
 
 Symptoms. — If the bullet has traversed the thorax above the level 
 of the fifth rib, and there are no signs of serious internal hemorrhage 
 (p. 277), it is probable that the upper part of the lung has been 
 wounded at its periphery. If the bullet is of small calibre, the 
 
100 GUNSHOT WOrXDS 
 
 pulmonary tissue expands and occludes the wounds of entrance and 
 exit in the lung, and little hemorrhage occurs into the pleural cavity. 
 A larger bullet produces more of a lacerated wound, and the signs of 
 hemothorax (sometimes pneumo-hemothorax ) quickly develop. Sub- 
 cutaneous emphysema (p. 72Sj is not infrequent. In nearly every 
 case the physical signs of a more or less diffuse bronchitis appear; 
 bloody mucus is expectorated; moderate fever occurs; and the patient 
 passes through an atypical attack of pneumonia. Dyspnea rarely 
 is severe, unless from internal hemorrhage, or from pneumothorax. 
 If the track of the bullet passes below the level of the fifth rib, it 
 may wound the diaphragm, or pierce this and entering the abdomen 
 wound the subdiaphragmatic viscera. In a patient under my care 
 at the Episcopal Hospital (March, 1909j, the wound of entrance was 
 in the sixth left interspace close to the sternum, and the bullet lodged 
 beneath the skin in the eleventh left interspace about three inches 
 from the spine. It perforated the pericardium in two places, without 
 wounding the heart; then entered the diaphragm, grooving the 
 esophagus; perforated the left lobe of the liver; reentered the dia- 
 phragm, three inches back of its first passage; passed through the 
 lower border of the lung, cut the intercostal artery near its origin, 
 and lodged outside the pleura, as before stated. In spite of prompt 
 operation, tlie patient died on the third day, of pneumonia. 
 
 Treatment. — Xo operation should be done except with the most 
 complete facilities for aseptic technique. Wounds above the level 
 of the fifth rib. not wotmding the heart or the root of the lung, seldom 
 require operation. The superficial wounds should be cleansed and 
 occluded with sterile dressings, and the affected side of the chest 
 strapped, as for fractured ribs (p. 323). Dyspnea is to be controlled 
 by opiates; stimulation by atropin and strychnin may be necessary; 
 for persistent hemoptysis, calcium chloride or horse serum may be 
 employed. In any case where the abdominal contents may have been 
 wounded, exploratory laparotomy is indicated. When dyspnea is 
 extreme, and the pleura is filled with fluid, it is better to open the 
 pleural cavity by an intercostal incision (in the seventh or eighth 
 interspace), and evacuate the blood. Mere exjoosure of the lung to 
 the air usually is sufficient to control hemorrhage from the bullet 
 track; if hemorrhage persists, the orifices in the lung should be 
 sutured, and wounds in the thoracic parietes tamponed, if ligation is 
 impossible. To accomplish these manoeuvres it may be necessary to 
 excise portions of one or both ribs bordering the intercostal incision. 
 When bleeding is arrested, the wound should be closed, with drainage. 
 Empyema is a not infrequent sequel, in cases treated with or without 
 operation. 
 
 Prognosis. — The mortality from penetrating gunshot wounds of the 
 chest has fallen from 60 to 80 per cent., in the wars of the RebelHon 
 and the Crimea, to about 20 per cent, in the Spanish- American and 
 South African wars (O'Reilly, 1908). Rochard (1909) has reported 
 a series of seventy-one cases of gunshot wounds of the lungs, in civil 
 
GUNSHOT WOUNDS OF SPECIAL STRUCTURES AND REGIONS 191 
 
 life; in only one was operation necessary; and Thiery (1909) stated 
 that anionjj fourteen cases of penetrating bullet wounds, and one of 
 stab wound of the lung, eleven patients recovered without opera- 
 tion; while of the four whose condition was so grave as to demand 
 operation, two succumbed. 
 
 Abdomen. — Gunshot wounds of the abdomen may involve only 
 the parietes, and in a patient with a very fat or pendulous abdomen 
 the bullet may enter in front and lodge in the groin or flank without 
 penetrating the peritoneum. In military surgery no operation should 
 be undertaken on the field of battle, except for alarming hemorrhage. 
 Doche (1909) has shown that when penetrating abdominal wounds 
 are treated by laparotomy on the field, more than 95 per cent, termi- 
 nate fatally; but if no operation is done, the mortality is only 50 to 
 55 per cent. If the patient be carefully transported to the nearest 
 military hospital properly equipped for such work, he may arrive 
 there still alive, and subsequently develop a localized abscess, fecal 
 fistula, or even intestinal obstruction, which may be treated success- 
 fully by a late operation. Meantime the non-operative treatment for 
 peritonitis advised in Chapter XXII should be adopted. 
 
 In civil life, where adequate facilities exist, immediate exploratory 
 laparotomy should be undertaken, and wounds of the viscera repaired. 
 No symptoms of intraperitoneal infection should be waited for. 
 If operation is done within the first twelve hours, nearly half the 
 patients should recover; after that time only one out of four recovers 
 (Coley). Though the mortality in civil practice, even after prompt 
 operation, is thus seen to be nearly as high as that which follows 
 non-operative treatment in military surgery, it must be remembered 
 that the character of the injuries in the former instances is more 
 serious, and that practically all such cases terminate fatally if not 
 operated upon; while in the case of wounds received in battle, the 
 gastro-intestinal tract usually is empty, the wounds are smaller, 
 clean-cut, and less contused; and many patients who die on the 
 battlefield are not included in the military statistics. 
 
 The diagnosis and operative treatment of penetrating wounds of 
 the abdomen are discussed in Chapter XXII. 
 
CHAPTER VIII. 
 
 AMPUTATIONS. 
 
 Amputation, derived from the Latin word meaning to lop off, 
 to prune, etc., is by surgeons usually confined in its ap])lication to 
 the removal of a limb, or part of a limb. If the member is removed 
 at a joint, the operation may be termed an exarticidation, or a dis- 
 articidcdion; if through the bones, the operation is an (tniijidation in 
 coidinudy. 
 
 Conditions Requiring Amputation. — Among the most frequent 
 and important are: (1) Avuhion, or traunudic amputation, of a limb; 
 here there is no alternative but to trim up the stump that is left so 
 as to hasten healing and secure good functional 
 result. (2) Compound fractures and luxations, 
 which sometimes leave the limb attached only 
 by a few shreds of muscle or a strip of skin. 
 (3) Lacerated and contused ivounds, even without 
 fracture, sometimes exhi})it such extensive 
 destruction of the soft parts as to demand 
 the removal of the limb. In general, if the 
 limb is sure to be useless if retained, or if it is 
 sure to become gangrenous, it should be re- 
 moved. (4) r/o/;///Y7/p, when constituting more 
 than a superficial slough, usually is a cause 
 for amputation. The special varieties of gan- 
 grene, and the proper time for amputation, as 
 well as the level where this should be done, 
 have been considered in Chapter II. (5) Dis- 
 eases of Bones and Joints. These are much 
 less often a cause for amputation now than 
 formerly. (6) Injury of the main artery of a 
 limb, when it occurs at a site which habitually 
 results in gangrene, usually is a cause for 
 amputation (p. 62). (7) Mcdignant tumors 
 frequently necessitate amputation. (8) De- 
 formity, including also certain non-malignant 
 tumors, may very occasionally be a cause for 
 amputation. 
 Instruments. — These include a tourniquet (Fig. lo7), or an Esmarclis 
 hand (Fig. 138) for controlling the circulation; amputating knives for 
 dividing the soft parts; periostcotome, or raspatory; retractors to guard 
 the soft parts from the saw; bone forceps, to steady the bone as it is 
 
 Fig. 137. — ^Screw tourni 
 quet applied to thigh. 
 
INSTIU'MENTS 
 
 193 
 
 sawed, in cases of axulsioii or traimiiitic amputation, and Itoiir iiipjx'r.i 
 to trim rouj'li edj^es oil' the hone after it has heen sawed; luniiostatic 
 
 Fig. 138. — Esniarch band, showing proper method of its application 
 
 Fig. 1.39. — Amputating instruments. 1. Large amputating knife. 2. Catlin (double- 
 edged knife). .3. Small amputating knife. 4. Metacarpal knife. 5. Periosteotome or 
 ra.spatorj'. 6. Phalangeal .saw. 7. Metacarpal saw. 8. Large amputating saw. 
 
 forceps, as well as ligatures, sutures, needles, and scissors. These 
 in.struments are illustrated in Figs. 139 and 140. 
 13 
 
194 
 
 AMPUTATIOXS 
 
 Tourniquet. — The screw tourniquet (Petit, WM)) is seldom employed 
 now, Ksmarch's elastic band (1873) having largely superseded it. 
 Before applying either, especially in shocked or anemic patients, 
 the limb should be elevated for a few moments, so as to empty it of 
 venous blood. The tourniquet, when used, should be ])laced upon 
 the limb so that the screw is either directly over the main vessels, or 
 at a point diametrically opposite to them, compressing them against 
 bone; and a compress (as a roller bandage) should be placed between 
 the tourniquet and the main vessels, so that greater pressure will he 
 brought to bear on them than on the surrounding soft parts. After 
 fixing the touniirjuet in j^lace by buckling the strap tight, the plates 
 
 •-^^^*^^ si^'?s5S:;^gs;^;sg^i^ 
 
 Fig. 140. — Amputating instruments. 1. Hemostatic foceps. 2. Curved hemostatic 
 forceps. 3. Fergusson's '"lion-jawed" bone-holding forceps. 4. Liston's bone-cutting 
 forceps ("nippers"). 5. Farabeuf's bone-holding forceps. 
 
 are separated by turning the screw, thus drawing the encircling strap 
 tighter and forcing the compress against the vessels until distal 
 pulsation is arrested. Esmarch's elastic band is wrapped around 
 the limb three or four times, each turn being directly superposed 
 upon, and being drawn a little tighter than the previous one, until 
 the circulation is arrested. If not drawn tight enough, it will increase 
 venous bleeding; if drawn too tight, it may cause local sloughing 
 and subsequent gangrene of the entire limb; or paralysis from pres.sure 
 on the nerves, especially above the elbow, when the ulnar or musculo- 
 spiral nerve may be injured. In emergencies the "Spanish windlass" 
 (Morel, 1G74) may be used (Fig. 1-il), or even Momburg's method of 
 hemostasis (p. 21(3). 
 
OPERA TI VE I' ROC ED URES 
 
 195 
 
 Amputating Knives. 'Vhv Iciij^'tli should he jilxHit one and a half 
 times the tlianieter of the linih to be removed, and the blade should 
 be from f to f of an inch wide; one of e'ifr,ht or ten inches is suitable 
 for the thi<;h or hip; one of six for the forearm, arm, or lejij; while 
 for the hand or foot a metaearj)al amputatin<^ knife (Fig. 1-^9, 4), 
 with a blade three inches long and | inch wide, is preferable. 
 Double edged catlins occasionally are used for the forearm or leg, 
 to aid in clearing the interosseous space. The rasjmtory is used to 
 scra])e up the })eriosteum before applying the saw, thus leaving a 
 curt" i)f periosteum to cover the end of the bone. The retractor is 
 made of muslin, being two-tailed for the humerus and femur (Fig. 
 142), and three-tailed for the forearm and leg (P'ig. 143). 
 
 Fig. 142. — Two-tailed muslin retractor, for amputations 
 of the arm and thigh. 
 
 Fig. 141.— The "Spanish 
 windlass." 
 
 Fig. 143. — Three-tailed retractor applied for an 
 amputation of the leg. 
 
 The amjyutativg saw is about ten inches long by two and a half 
 wide; strong-backed, and with widely set teeth. A smaller saw 
 is used for the hand and foot. Bone-ni'ppers are sometimes used 
 for amputating phalanges, though they are apt to splinter the 
 bone; and if larger bones are properly sawed, there should be no 
 rough edges to trim off. Ligatures are of absorbable material, as 
 are the buried sutures; skin sutures usually are of silkworm gut. 
 
 Operative Procedures. — A patient who is to have a limb removed 
 usually is in a weakened and precarious state, either from shock 
 and hemorrhage following an accident, or from the cachexia of chronic 
 disease. Hence it is the surgeon's duty to take special pains to 
 
196 AMPUTATIONS 
 
 prevent loss of bodily heat, and needless waste of time. In cases 
 of accident it frequently is necessary to prepare the limb for ampu- 
 tation after the patient is on the table, while the anesthetic is being 
 administered. The surgeon and his first assistant should be ready 
 to commence the operation the instant that the patient is under the 
 anesthetic, and the preparation of the limb should be complete at 
 the same time. While one assistant raises the limb, the surgeon 
 applies the tourniquet, or if he entrusts this important duty to an 
 assistant, he should make sure before commencing his operation that 
 the circulation is properly arrested and that there is no danger of 
 the tourniquet slipping. One assistant should give his entire attention 
 to the tourniquet throughout the operation. Another assistant holds 
 the limb in a convenient position, clear of the table, and the surgeon, 
 standing with his left hand to the patient's trunk, ^ divides the soft 
 parts, as will be presently directed; then raises the periosteum for 
 about an inch; and, while the soft parts are drawn out of the way and 
 protected by the retractor, saws the bone, his assistant guarding 
 against binding of the saw by the manner in which he holds the 
 limb. As soon as the limb has been removed, the surgeon applies 
 to the face of the stump a folded towel, lightly wrung out of very 
 hot corrosive sublimate solution; this checks the slight venous ooze, 
 and as it is gradually withdrawn, the surgeon catches with hemostats 
 all the vessels large enough to have names, and ties them all. The 
 main artery and vein of the arm or thigh should be tied separately; 
 smaller arteries may be included in one ligature with their accom- 
 panying veins. Then another hot antiseptic towel is applied to the 
 face of the stump, and, the limb being held as nearly vertical as 
 possible, the tourniquet is completely removed. If it is only partially 
 loosened, venous bleeding is increased. If the surgeon has done the 
 operation with due care there should now remain only a few oozing 
 points in the muscular masses, which can be controlled by sutures. 
 Any redundant tendons or nerves are next retrenched, and the peri- 
 osteum drawn down over the bone. Hemorrhage from the medulla, 
 w^hich is unusual, should be controlled by plugging wdth muscle tissue, 
 by packing with Horsley's wax, or in emergency with gauze. Finally, 
 the stump is closed, with a few buried mattress sutures of chromic 
 catgut approximating the ends of opposing sets of muscles. A rubber 
 drainage tube is placed across the face of the stump, just beneath the 
 skin, and the skin is closed with interrupted sutures of silkworm gut. 
 Dressing the Stump. — ^Moderate pressure, rest, and mechanical 
 protection are necessary. Abundant sterile gauze dressings are 
 applied, and in a certain definite manner. Ruffled gauze is placed 
 around each end of the tube, one end of which may be left long and 
 brought out of the deep into the superficial dressings, as described 
 at p. 160. The special amputation dressing is cut as shown in Fig. 
 144; the horizontal portion is placed beneath the limb, and folded 
 
 ' In amputating the left lower extremity he stands between the patient's legs. 
 
CIRCLLAli A MITT A TIOX 
 
 197 
 
 Fig. 144. — Method of cutting and ap- 
 plying gauze for dressing an amputation 
 stump. 
 
 around it. the xcrtical portion Ix'iii^^ then t'oMcd up over the end of 
 the stump. .\ second siuiilar dressin<;' is apphed oxer the first, in 
 reverse order, the horizontal ])ortion hein^^ phiced dhort' the linih, 
 and the \'ertieal flap hein^ drawn 
 <h)\vn over the end of the stunij) 
 Ix'fore the side pieces are fohled 
 around it. C)\er tlie gauze dress- 
 ings an abunilant amount of 
 sterih' absorbent cotton is ar- 
 ranged, burying the end of the 
 tul)e, and the whole is band- 
 aged snugly on to the stumj). 
 It is surprising how much dimi- 
 nution in size an apparently 
 bulky dressing undergoes when it 
 is properly bandged. Next the 
 limb is bandaged firmly toa splint, 
 which projects some inches be- 
 yond the end of the stump. It 
 is never safe to assume that cases 
 
 of amputation, especially recent accidents, will be free from traumatic 
 delirium, and the proper time to protect the limb from injury is before 
 the delirium develops. The stump should be kept as nearly vertical as 
 possible for twelve hours. Usually the drainage tube may be removed 
 at the end of twenty-four to thirty-six hours ; and the stump need not 
 be dressed, if all goes well, until time to remove the skin sutures. 
 
 Methods of Operating. — Every method of amputating may be 
 considered a variety of either the circular or the flap method. The 
 circular method is to be preferred whenever a choice is possible; 
 it is suited for all limbs where the bones are approximately in the 
 centre of the soft parts (lower forearm, arm, thigh), provided the 
 limb is not conical in shape. It is not desirable in amputations at 
 joints, nor in the leg, where a weight-bearing stump is sought, since 
 the cicatrix always falls across the face of the stump. 
 
 Circular Amputation. — In this method all the tissues of the limb 
 are severed by circular incisions, the skin at the lowest, the muscles 
 at an intermediate, and the bone at the highest point ("triple in- 
 cision" method). The surgeon passes the knife under, around, and 
 over the limb, so that its point is down, and its back toward his own 
 face (Fig. 145); then, pressing the heel of the knife well into the flesh, 
 with one long steady sweep he divides the skin and subcutaneous 
 tissues down to the deep fascia, the blade ending with its point exactly 
 in the place where its heel began the incision. If the skin does not 
 now retract sufficiently, the surgeon dissects it up, with the same 
 knife, for a distance equal to half the diameter of the limb, taking 
 care always to direct his blade toward the deeper structures so as 
 to leave uninjured the cutaneous vessels, and thus ensure the vitality 
 of the skin. Then the muscles are similarly divided down to the 
 
198 
 
 AMPUTATIONS 
 
 Fig. 145. — Circular amputation of the thigh, showing method of holding the 
 knife as the first incision is started. 
 
 Fig. 146. — Rkiagraph of stump resulting from amputation of leg by modified 
 Sedillot method. 
 
FLAP AMPI'TATIOS 199 
 
 bone, with the same knife, by a eircular cut at the point of refleetion 
 of the skin. The nuiseles are not separated from the j)eriosteum 
 further than is necessary, but this is cut througli by tlie periosteotome, 
 an<l serajx'd upward for an incli or more. In the forearm and h'g 
 the interosseous space nuist be ck'ared also; in doing this the surgeon 
 shoukl stu(Hously avoid turning the edge of his knife uj)\vard, toward 
 the patient's trunk, for fear of nicking bloodvessels higher than they 
 can be conveniently tied. When the bone has been cleared fo.r an 
 inch or over, the muslin retractor is applied, each end overlapping 
 the other, and all being drawn upward by an assistant. The bone 
 is then sawed, at right angles to its long axis. In the forearm both 
 bones are sawed at the same level, and simultaneously; in the leg, 
 the fibula is sawed first and at least half an inch higher than the 
 tibia (Fig. 146). After suturing the muscles, the skin incision may 
 be closed transversely or antero-posteriorly, as seems best. 
 
 Sometimes in a conical limb there is difficulty in dissecting back 
 the circular cuff of skin, as above described; then it may be slit at 
 one or two points. If slit at only one point, and the angles rounded 
 off, this constitutes the Oval or Elliptical Method, which is habitually 
 used in many amputations, without the formality of commencing 
 it as a circular amputation, by making the first skin incision in the 
 form of an ellipse. If the cuft' of skin is slit at two points, and the 
 angles rounded off, the amputation becomes one by skin flaps, com- 
 monly called the Modified Circular Method. 
 
 Flap Amputation. — The flaps may include skin only, as in the 
 modified circular method; the skin and superficial muscles; or the 
 entire muscular mass with the skin. The flaps may be rectangular 
 or curved in outline, and may be cut from without inward or by 
 transfixion. They always should be of equal breadth at their base, 
 whether they are of equal or unequal length. Their combined length 
 should equal one and a half times the diameter of the limb. Care 
 should be exercised to have the main bloodvessels in one flap or the 
 other (usually in the shorter), and not at a point where they may be 
 slit up as the flaps are being formed. In amputating by transfixion 
 the surgeon raises the tissues to be cut with his left hand, and, entering 
 the point of the knife at the side of the limb nearest himself, pushes 
 it across and around the bone, and brings its point out diametric- 
 ally opposite its place of entrance. The flap is then formed by 
 cutting first downward and then rapidly outward, with a vigorous 
 sawing motion. The knife is then reentered as before, passing on 
 the opposite side of the bone, and the second flap is cut. The remain- 
 ing fibres are then divided by a circular sweep, and the operation 
 terminated as already described. The flap which contains the prin- 
 cipal bloodvessles should be cut last. Frequently it is more con- 
 venient to form the first flap by cutting from without inward, and the 
 second flap only by transfixion. Though an amputation may be 
 performed more rapidly by transfixion, this method has lost in favor 
 since the introduction of anesthesia; since by cutting from without 
 inward the flaps may be more accurately shaped, and the main 
 
200 
 
 AMPUTATIONS 
 
 bloodvessels may be severed transversely, instead of obliquely as 
 frequently hai)pened in cutting flaps by transfixion. 
 
 Multiple Amputations. — It is occasionally necessary to remove 
 two or more limbs at the same time. Under such circumstances it 
 
 is l)est to do the amputation of 
 greatest magnitude and severity 
 first; and for the same surgeon to 
 proceed immediately afterward to 
 remove the second and third limb, 
 if the patient's condition warrants 
 the continuance of the operation. 
 If it does not, hemorrhage from 
 the remaining limb or limbs must 
 be temporarily controlled, and 
 Further operation postponed. For 
 two or more surgeons to operate 
 on different limbs simultaneously 
 usually increases the shock to the 
 l)atient. Multiple amputations for 
 gangrene following frostbite are 
 much less serious than those for 
 traumatic cases. Fig. 147 shows the 
 result of synchronous amputation 
 of both arms in a patient imder 
 the care of Dr. H. C. Deaver, in 
 the Episcopal Hospital. 
 Structure and Diseases of Stumps. — A stump not only goes through 
 the processes of inflanmiatory reaction, cicatrization, and contraction; 
 but there also occurs actual atrophy of the muscular tissues from 
 disuse; the bone becomes rounded off and atrophies; the nerves degen- 
 erate, and sometimes become bulbous and painful from the develop- 
 ment of fibromas upon their ends.^ The muscles occasionally become 
 unduly atrophied and retracted, leaving the ends of the bone covered 
 only bj' skin, or even causing the incision to break open, and pro- 
 ducing a painful ulcer. Sometimes, from continued growth of bone, a 
 conical stump is formed (Fig. 148). This usually is due to the natural 
 development of the bone, being seen oftenest in amputations of the 
 upper arm in children, as the growth of the humerus takes place 
 chiefly at the upper epiphysis. Sometimes a conical stump forms 
 in the leg in childhood, the growth occurring from the upper epiphysis 
 of the tibia; whereas in the forearm and thigh, the greater part of 
 the growth comes from the lower epiphyses. For conical stumps, 
 and for intractable ulcers, adherent to the bone, which cannot be 
 cured by palliative means, there is no remedy short of re-amputation, 
 which, fortunately, is a much less serious operation than amputation. 
 It sometimes is possible to resect the end of the bone subperiosteally, 
 without doing a formal amputation again. 
 
 1 Mumford (1910) sutures the ends of the nerves to each other, to prevent the 
 development of false neuromas. 
 
 Fiii. 147. — Douhlo amputation 
 (crush) eight weeks after operation. 
 (Dr. H. C. Deaver's case.) Episcopal 
 Hospital. 
 
DISI'JASKS OF ST r MI'S 
 
 201 
 
 A (/ood sfiniip is one which is paiiik'ss and which, in tlic lower 
 extremity, can he nsed to snjjport the weight of the body tiirougii 
 
 Fig. 148. — Conical or sugar-loaf stump from continued growth of bone after ampu- 
 tation in early youth. From a patient in the Pennsylvania Hospital under the care 
 of the late Prof. Ashhurst. 
 
 an artificial Hmb. The bones sliould be well covered w^ith soft parts, 
 and these soft parts should not be adherent to the ends of the bone; if 
 there are no such adhesions it makes no particular difference whether 
 
 the cutaneous cicatrix lies across the 
 end of the stump or at one side; 
 but there are much less apt to be 
 adhesions to the bone if the cicatrix 
 of skin as well as of muscle lies to 
 one side of rather than directly over 
 the end of the bone. Few stumps 
 will bear, by direct pressure on their 
 ends, the entire weight of the body, 
 and most artificial limbs are made 
 to obtain their chief support from 
 
 Fig. 149. — Bier's osteoplastic 
 method of amputation. The bones 
 are sjjwed at two levels, and a flap 
 of the tibia turned acrcjss the ends 
 at the last section. 
 
 Fig. 150. — Amputation of leg by aperiosteal 
 method of Bunge. 
 
202 
 
 AMPUTATIONS 
 
 surrounding bony points (head of the tibia, tuberosity of the ischium). 
 But Bier (1895) has advocated an osteoplastic raethofl of amputating, 
 after the Pirogoff principle, by means of which end-bearing stumps 
 may be obtained (Fig. 149). Bunge (1905) has found that by sawing 
 the bone 2 mm. below the level at which the periosteum is dixided, 
 and scraping out the marrow cavity for the same distance, end-bearing 
 stumps may be obtained without 
 any osteoplastic operation. He 
 makes his flaps of skin only (Fig. 
 150). The oval method is suitable 
 for such cases. I have used this 
 method with perfect success (1911) 
 (Fig. 151). 
 
 Fig. 151. — End-ljoarinK .stump (apori- 
 osteal method of Buiigej. Patient bearing 
 all his weight on the stump twenty-five 
 days after amputation. Episcopal Hospital. 
 
 Fk;. I.jL'. — .Ain|Hii.iti'iii for eineniatic 
 prosthesis; freely iiiovahlc stump secured 
 by a loop composed of biceps and triceps. 
 Episcopal Hospital. 
 
 Cinematoplastic Amputations. — Vanghetti (1906) and other surgeons 
 have devised and practised methods of amputating the upper extremity 
 which provide for voluntary motion in the prosthesis. In cases of 
 recent accidents, the limb is amputated in the ordinary manner, and 
 when the patient has recovered his normal health, the stump is re- 
 opened, and the flexor and extensor muscles are sutured to each other 
 in the form of a loop, over the end of the bone, which is resected if 
 too long; the loop so formed is covered on all sides by flaps of skin. 
 When healing is complete a stout cord is passed through this tendinous 
 loop, and each end of the cord is attached to the mechanism of the 
 prosthesis. The patient can then, by drawing on the flexor or extensor 
 side of his tendinous loop, flex or extend the artificial hand. I have 
 adopted this method in some cases, but so far have not found any 
 
MORTALITY AFTER AMI'CTATIOX 
 
 203 
 
 manufjK'turor in this country who will furnish the desired cinematic 
 prosthesis (Fi|;. 152j. Another method, practised hy Francesco (1908), 
 is to detach tlie end of bone from its diaj^hysis, still leaving it buried 
 in the muscular mass at the end of the stump. When healing is 
 comi)lete, a ring of iron is applied around the stump l>etwecn the 
 knob of bone antl the diaphysis frf)m which it has been detached. As 
 the detached knob of bone is voluntarily movable, the ring above it 
 can be inclined in any direction, and through attached cords transmits 
 the movements to the prosthesis. 
 
 Mortality after Amputation. — Although this depends much more on 
 the condition of the patient than on any other single factor, it is 
 nevertheless proper for the surgeon to be familiar with the relative 
 mortality of amputations for injury and for disease; and, in cases 
 of injury, with that which accompanies primary, intermediate, and 
 secondary operation; as well as the average mortality which attends 
 amputation in different regions of the body. Primary amputations 
 are those done before the inflammatory process has had time to 
 develop — generally speaking, those done within twelve hours of 
 injury; intermediate amputations are those done during the height of 
 the inflammatory process; and secondary amputaiions are those 
 performed after its subsidence, when the operation resembles that 
 done for disease. As a rule, the lowest mortality attends primary' 
 amputations; and though since the introduction of antiseptic methods 
 there is less inflammatory reaction than formerly, nevertheless 
 intermediary amputations still give the highest mortality. In the 
 case of secondary amputation the results are not so good as they 
 seem, many patients being too shocked for primary amputation, 
 and dying before secondary amputation can be attempted. The fol- 
 lowing table shows the death rate attending amputations in various 
 portions of the body, for injury and for disease, as observed at the 
 Episcopal Hospital, Philadelphia, 1900 to 1913 inclusive: 
 
 Amputations at the Episcopal Hospital, Philadelphia, 190C 
 
 1-1913 
 
 
 
 
 Inclusi\t;. 
 
 
 
 
 
 
 For injury. 
 
 For disease. 
 
 
 
 Recov- 
 
 
 Mortality, 
 
 
 Recov- 
 
 
 Mortality, 
 
 Region. 
 
 No. 
 
 ered. 
 
 Died. 
 
 
 per cent. 
 
 No. 
 1 
 
 ered. 
 1 
 
 Died. 
 
 per cent. 
 
 Hand . . . 
 
 17 
 
 17 
 
 
 
 
 
 Wrist-joint 
 
 1 
 
 1 
 
 
 
 
 
 ■ • 
 
 
 
 Forearm . 
 
 10 
 
 10 
 
 
 
 
 ii 
 
 3 
 
 6 
 
 
 Arm .... 
 
 30 
 
 29 
 
 1 
 
 3.3 
 
 3 
 
 2 
 
 1 
 
 33.3 
 
 Shoulder . 
 
 8 
 
 8 
 
 
 
 
 4 
 
 3 
 
 1 
 
 25.0 
 
 Interscapulo- 
 
 
 
 
 
 
 
 
 
 thoracic 
 
 1 
 
 
 
 1 
 
 100.0 
 
 
 
 
 
 Foot ... 
 
 18 
 
 17 
 
 1 
 
 5.0 
 
 3 
 
 2 
 
 1 
 
 .33.3 
 
 Leg .... 
 
 54 
 
 49 
 
 5 
 
 9.2 
 
 16 
 
 S 
 
 8 
 
 50.0 
 
 Knee or knee-joint 
 
 6 
 
 6 
 
 
 
 
 3 
 
 1 
 
 2 
 
 66.0 
 
 Thigh . . . 
 
 27 
 
 25 
 
 2 
 
 7.4 
 
 18 
 
 10 
 
 8 
 
 44.4 
 
 Hip ... . 
 
 3 
 175 
 
 1 
 
 2 
 ^12 
 
 66.6 
 6.9 
 
 1 
 52 
 
 1 
 
 31 
 
 
 
 ... 
 
 Total , . . 
 
 163 
 
 21 
 
 40.3 
 
204 AMPUTATIONS 
 
 It has usually been taught, and it is still stated by many surgeons, 
 that amputations for disease are attended by a much lower death 
 rate than those for injury. While this was perfectly true before the 
 general adoption of antise])tic methods and modern methods of 
 treating shock and hemorrhage, I tiiink the relati(jn is now reversed, 
 though the extremely high mortality shown for amputations for 
 flisease in the above table is to be explained by the fact that a large 
 majority of the patients were suffering not from tuberculous arthritis 
 or malignant tumors, l)ut from diabetic or senile gangrene. Yet 
 the mortality in amputations for disease in this series is scarcely 
 higher than that which attended amputations for injury before the 
 antiseptic period. 
 
 Treatment of Crushed Limbs. — The first thing to do is to control 
 hemorrhage and combat shock. The limb should be held vertically, 
 and an Esmarch band applied as near to the crushed area as practicable; 
 the foot of the bed should be raised, and in cases of grave anemia the 
 other extremities should be bandaged from the periphery toward 
 the trunk (auto-transfusion) . The application of external heat, and 
 other methods detailed at p. 175, should be employed for shock. 
 If any vessels can be recognized in the wound they should be ligated ; 
 and any projecting nerves should be injected with a sterilized eucain 
 solution (2 per cent.), since by nerve blocking it is possible to check 
 the peripheral impulses which cause shock. Amputation should be 
 done as soon as the yatient reacts, or at once if the shock is not marked. 
 // reaction once occurs no delay in amjmtating should he allowed, as 
 the improvement frequently is only fleeting, unless the mangled 
 limb is removed. The Esmarch band should not be left in one place 
 more than four or five hours; sometimes, on removing it, no further 
 bleeding will occur; but usually a little ooze persists, and the band 
 should be re-applied higher on the limb. In a few hours its position 
 should again be shifted (applying a second before removing the first, 
 if necessary), since in this way it is possible to keep the bleeding 
 checked without endangering the vitality of the parts above the 
 wound. 
 
 If the patient does not react, or if, in spite of the skilful application 
 of the Esmarch band, oozing of blood persists, and seems to prolong 
 shock, the surgeon must consider whether the mere presence of the 
 mangled extremity is not detrimental, and whether by resorting to 
 amputation at once he will not obviate the tendency to death better 
 than by delay. In such cases delay is fatal with extremely few 
 exceptions; but by prompt operation, even "under desperate circum- 
 stances, a life is occasionally saved. In such a patient under my 
 care at the Episcopal Hospital (March 12, 1909), I amputated the 
 thigh, and though the pulse could not be felt for nearly two days 
 subsequently, recovery ensued. In such cases speed in operating 
 is important; the time consumed need not exceed ten or fifteen 
 minutes. 
 
SPECIAL AMI'l'TA TIONS 
 
 205 
 
 SPECIAL AMPUTATIONS. 
 
 Amputations of the Hand. — Though removal of portion of the 
 hand is ro(iiiire<l frcciuciitly, the surgeon should exercise tiie utmost 
 conservatism; no artificial contrivance can be as useful as the human 
 hand, and though amputation of a portion of it is often a less tedious 
 and more brillant oi)eration than partial exicision and careful suture, 
 yet judicious attempts at the latter are not seldom attended by 
 gratifying results (Figs. 118 and 119). 
 
 Fig. 153. — Tendinous insertions in the middle finger: a, deep flexor; b, superficial 
 flexor; c, extensor; d, luinbrical; e, exten.sor carpi radialis brevior. Note the uselessness 
 of the proximal phalanx (2), unless the insertion of the superficial flexor tendon is 
 retained in the middle phalanx (.3) , or unless 6 is sutured to c over the end of 2. (After 
 Waring.) 
 
 Amputation of the Fingers. — Xo tourniquet is required, and local 
 anesthesia usually is sufficient. This is secured by injecting a few 
 drops of 2 per cent, eucain solution at four points around the base 
 of the finger, blocking the digital 
 nerves. It is best to remove the 
 fingers at a joint, but amputation 
 is frequently done through the 
 proximal or middle phalanx of the 
 index and fifth fingers; this is 
 then divided with a small saw or 
 
 Fig. 154. — The finger-joints. 
 
 Fig. 155. — Amputation of the fingers 
 by the racket-shaped incision. 
 
 cutting forceps. The middle and ring fingers are of comparatively 
 little u.se, unless part of the middle phalanx is retained (P'ig. 15.3); 
 hence it is better to amputate at the metacarpal joint than to save 
 only part of the proximal phalanx, unless the tendons can be sutured 
 
206 
 
 AMPUTATIONS 
 
 to each other over the end of the stump. The position of the joints 
 must be borne in mind (Fig. 154), the usual error being to expect to 
 find them too high. In amputation by the racket-shaped incision 
 (Fig. 155), the first incision, on the dorsum, opens the joint, and 
 as the finger is sharply flexed the lateral ligaments are divided, and 
 the palmar flap is formed by passing the narrow-bladed knife between 
 the ends of the bones and cutting from within outward. It is easier 
 to preserve the tendons if a short extensor and long flexor flap are 
 employed. The digital arteries are ligated, the flexor and extensor 
 tendons sutured to each other by buried sutures; and the stump 
 is closed by bringing up the palmar flap and suturing it transversely. 
 This is known as the "poor man's amputation" because the scar is 
 carried away from the palmar surface and the stump is covered with 
 the tough palmar skin. If the palmar surface is destroyed by disease 
 or injury, a dorsal flap may be used ("rich man's amputation"). 
 Two lateral flaps are sometimes employed. 
 
 Fig. 156. 
 
 -Partial amputation of right hand for crush. Everj-thing but the 
 thumb removed. Episcopal Hospital. 
 
 In amputation at the vietacarpo-phalangeal joints the oval method 
 is to be preferred; in the case of the index and fifth fingers, the apex 
 of the oval is placed on the radial and ulnar borders of the joint, 
 instead of on the dorsum. The head of the metacarpal bone of the 
 two middle fingers sometimes is removed for cosmetic reasons. Am- 
 putation of the thumb is done by making a palmar flap whenever pos- 
 sible. Amputations through the metacarpal bones are done by antero- 
 posterior flaps, saving as much of the palm as possible, and making the 
 necessary incisions on the back of the hand. Owing to the variety 
 and irregularity of the injuries to the soft parts and bones in such 
 cases, each one is a rule to itself, and the surgeon must exercise his 
 ingenuity in saving whatever may prove useful, attaching it to the 
 stump, and covering it with skin flaps in any way possible (Fig. 156). 
 
 Amputations through the wrist-joint are seldom employed; a long 
 palmar flap should he cut, ami the triangular cartilage should be 
 retained, so as to aid in the preservation of rotation. 
 
 Amputations of the Forearm. — In the lower half of the forearm 
 I think the circular method is the best form of amputation, while 
 below the elbow the modified circular, with antero-])osterior skin 
 flaps is quite satisfactory (Fig. 157). Some surgeons employ Teale's 
 
SPECIA L A M I' LIT A TIOXS 
 
 207 
 
 mctlKul above the wrist: in this two ri'ct an, pillar Hai)s arc formed, the 
 width of eaeli heiiii; half the ('ircniiiference of the liinl); the longer flap 
 
 Fu;. 157. — Aiitt'iinr-posterior skin flaps, two inches Ix'low dhow. Episcopal Hosj)ital. 
 
 (formed from the flexor surface) is exactly square, while the shorter 
 flap is only one-fourth as long (Fig. 158). 
 
 Fig. 158. — Teale's method of amputation. 
 
 Amputation at the Elbow. — This may be done by the oval method, 
 taking a long skin flap from the thick skin covering the upper part 
 of the ulna; or by antero-posterior flaps, the anterior being longer 
 and including the muscular masses arising from the condyles as well 
 as the brachialis anticus. The joint is entered just above the head 
 of the radius. 
 
 Amputation through the Arm. — The circular method is suitable 
 for any level up to the insertion of the deltoid; above this point lateral 
 flaps are to be preferred. Injury by the saw to the musculo-spiral 
 nerve is to be avoided in amputations of the middle third; and the 
 incisions in the upper third should respect the circumflex nerve as 
 it enters the posterior surface of the deltoid. In cases of high ampu- 
 tation of the arm the tourniquet is applied with the screw over the 
 acromion and a large pad in the axilla over the vessels which are 
 thus compressed against the head of the humerus as the arm is well 
 abducted; or the bloodless method of Wyeth for amputation at the 
 shoulder-joint may be adopted. 
 
 Amputation at the Shoulder-joint. — (Morand, before 1715.) Hemo- 
 stasia is l)est secured by Wyeth's method (1889): two long steel 
 pins are used, one entjering in front of the acromion and travers- 
 ing the anterior axillary fold, to emerge close to the chest; w'hile 
 the other passes from behind the acromion to the border of the 
 posterior axillary fold, also close to the chest. The points of these 
 pins should be guarded by sterile corks. An Esmarch band 
 is then wrapped tightly three or four times around the shoulder, 
 passing from above the acromion around the armpit between 
 
208 
 
 AMPUTATIONS 
 
 the pins and the chest (Fig. 159). This band is effectually pre- 
 vented from slipping down by the steel pins, and the surgeon can 
 form his flaps in any fashion below them. If these pins are not 
 available, the surgeon may have the subclavian artery compressed; 
 or may cut down in the axilla and do a preliminary ligation of the 
 axillary artery in its first portion. I adopted the latter method in 
 
 Fig. 159. — Wycth's pins applied for 
 amputation at the shoulder. 
 
 Fig. 160. — Incisions for amputation at 
 the shoulder by Larrey's method (external 
 racket). 
 
 Fig. IGl. — Incisions for amputation at 
 the shoulder by Spence's method (ante- 
 rior racket). 
 
 Fig. 162. — Incisions for amputation at 
 the shoulder by Dupuytren's method 
 (external flap). 
 
 one case, in order to inject the brachial plexus with eucain, for the 
 purpose of preventing shock from the amputation ; but I found, Avhat 
 is frequently the case, that the axillary artery still bled, when severed 
 below the ligature, from the collateral circulation through the sub- 
 scapular branch; a second ligature was therefore required. 
 
 The only form of amputation habitually practised at the shoulder- 
 joint is the racket method, though it has many modifications, known 
 
SPECIAL AMl'UTA TIONS 
 
 209 
 
 l)y various iiainos. 'I'lic operation of Larrcy (ISI7), (external racket 
 method), is now very seldom enii)loye(l {V\^. KiO). In Spence's amj)U- 
 tation (lcS()7), (anterior racket method) the incision hejjins midway 
 between the acromion and the coracoid, where the point of an oval is 
 formed, then passes down nearly to the insertion of the deltoid, and 
 there encircles the arm trans\'ersely (Fi<!;. Kil). J)npnytren's ampu- 
 tation (1S12), hy a larj^e deltoid flap, ori<,anally was i)erformed by 
 transfixion: the knife entered at the front, just within the acromion, 
 and its point emer<i;ed behind at the level of the spine of the scapula; 
 the Hap extended down almost to the insertion of the deltoid. After dis- 
 articulation a short internal Hap was cut from within outward (Fifij. 1()2). 
 A form of amputation midway between these two extremes (Spence 
 and Dupuytren) may be termed the lateral flap method, the internal 
 Hap bein^j; very short, and the external being formed })y an incision 
 beginning as in Dupuytren's and Spence's methods, but not extending 
 so high i)osteri()rly as the former. 
 
 Lateral Flap Method. — The knife is entered between the coracoid 
 and acromion processes, and cutting through all the tissues down 
 to the muscle is carried downward in a broad sweep, nearly to the 
 insertion of the deltoid, and up again as far as the posterior axillary 
 fold. The flap thus marked out is deepened to the bone, and raised 
 so as to expose the tuberosities of the humerus. With the arm of 
 the patient held close against his chest, and rotated out as far as it 
 will go, the point of the amputating knife opens the capsule by a 
 transverse cut between the acromion and the tuberosities, and then 
 detaches the subscapularis, attached to the lesser tuberosity, and 
 severs the long head of the bi- 
 ceps. The arm is then forcibly 
 rotated inward, and the muscles 
 attached to the greater tuber- 
 osity are severed. The head of 
 the bone then drops from the 
 glenoid ca\ity, and may be fur- 
 ther freed by cutting the mus- 
 cles attached to the bicipital 
 groove. The amputating knife 
 is then passed across the joint 
 between the upper end of the 
 humerus and the axilla, and the 
 axillary tissues are cut from 
 within outward. After ligating the vessels and retrenching the 
 nerves, the Esmarch band and the pins are removed, the muscles of 
 the two flaps are sutured to each other, and the skin closed, Avith 
 provision for drainage from the two ends of the incision. 
 
 This form of amputation may be very quickly performed, and 
 it leaves a very excellent stump (Fig. 163). Its advantages are (1) 
 the first incision is the same as that used for excision of the shoulder- 
 joint, and permits inspection of the parts before the amputation is 
 14 
 
 Fig. 163. — Stump resulting from lateral 
 flap method of shoulder amimtation (modi- 
 fied Dupuytren's). Episcopal Hospital. 
 
210 
 
 AMPUTATIONS 
 
 performed; (2) the posterior circumflex artery and circumflex nerve 
 are not divided, if the knife is kept close to the bone in detaching 
 the deltoid flap; (3) either the external or internal flap may be re- 
 trenched at the expense of the other, in case of injury or disease 
 invading one; (4) in emergencies the entire operation, up to the 
 division of the inner flap, may be completed almost bloodlessly 
 without the use of a tourniquet; and the main vessels can readily 
 be controlled by the fingers of an assistant before the inner flap is 
 severed; or the third portion of the axillary artery may be ligated 
 through the first incision, before raising the external flap or dis- 
 articulating; finally (5) it is more nearly universally applicable than 
 any other method of shoulder-joint amputation. 
 
 Amputation above the Shoulder. — The interscapulo-ihoracic ampu- 
 tation (Berger's operation, 1887) comprising removal of the entire 
 
 upper extremity, is employed usually 
 for disease, especially sarcomas of the 
 shoulder or scapula, though it is occa- 
 sionally required for injur}'. The oper- 
 ation is best performed by opening the 
 sterno-clavicular joint, raising the clavi- 
 cle (Le Conte, 1899), and detaching the 
 pectoralis minor from the coracoid ; then 
 the subclavian artery and vein are doubly 
 ligated outside of the scalenus anticus, 
 and divided; the brachial plexus is next 
 cut, after injecting it proximally with 
 eucain; the transversus colli and supra- 
 scapular arteries are ligated and divided, 
 and finally the scapula is dissected away 
 from the chest. The incisions used are 
 shown in Fig. 164. Berger (1905) col- 
 lected ninety-four cases of this operation, 
 with eight deaths, a mortality of 8.5 
 per cent.; in the twenty-five cases in which the tumor originated 
 in the scapula there were five deaths, and only three deaths among 
 the sixty-nine cases of sarcoma of the humerus. 
 
 Amputations of the Foot. — The phalanges may be amputated by 
 an oval incision, with a plantar flap; or, preferably, by antero- 
 posterior flaps. The heads of the metatarsal bones should be 
 retained whenever possible, as they aff"ord great support in walk- 
 ing. A single metatarsal bone, with its annexed digit, may be removed 
 by a dorsal incision. Amputations through the metatarsal bones 
 are sometimes performed for gangrene following frost-bite; a long 
 plantar and short dorsal flap are used. Amputation at the tarso- 
 metatarsal joint (Lisfranc, 1815) is difficult to perform, and is 
 seldom employed (Fig. 105). To avoid the difficulties of dis- 
 articulation Hey (1799) sawed off the projecting internal cuneiform, 
 while Skey (1850) removed the base of the second metatarsal by 
 
 Fig. 164. — Incisions for intersca 
 pulo-thoracic amputation. 
 
SPECIAL AMI'UTA TIONS 
 
 211 
 
 I'littini]; forceps. It is better to saw tlirougli tlic foot at any level 
 required by tlie length of available skin! flaps (Hancock). Ampu- 
 tation at the mcdio-tarsal joint (Chopart, 1792) is performed thus: 
 a transverse incision, convex forward, is made across the dorsum 
 
 Fig. 165. — The t;irsal joints: .1, astragalus; Ca, calcaiieuni; <S', scaphoid; C, cuboid; 
 1, 2, 3, cuneiform bones. Note the irregularity of Lisfranc's joint (between the tarsus 
 and metatarsus). Chopart's joint is between the astragalus and calcancum posteriorly, 
 and the scajjhoid and cuboid anteriorly. The subastragalar joint includes the astragalo- 
 scaphoid joint as well as the astragalo-calcanoan. 
 
 of the foot, from a jioint midway between the external malleolus 
 and the tuberosity of the fifth metatarsal, to a point half an inch 
 behind the tubercle of the scaphoid; the plantar flap extends from 
 the same points as far forward as the line 
 of the metatarso-phala ngeal joints. The usual 
 error is to make this flap too short. By for- 
 cing the foot downward, after making the 
 dorsal flap, the joint between the calcaneum 
 and cuboid is easily opened on the outer side; 
 and the disarticulation is completed by pass- 
 ing between the astragalus and scaphoid. 
 Though the scaphoid has repeatedly been 
 left, unintentionally, it has not interfered 
 with the result. Careful dressing and after- 
 treatment are rec^uired to keep the calf mus- 
 cles from drawing the cicatrix on to the sole 
 of the foot. The patient walks with the 
 ankle-joint in slight plantar flexion (Fig. 166). 
 
 Amputation at the Ankle-joint (Syme, 
 1843), including removal of the maUeoli, is 
 performed by making a heel flap by cutting 
 across the sole from one malleolus to the 
 other. Subastragalar amputation (Textor, 
 1841) retains the motions of the ankle-joint, 
 and greater length of limb. 
 
 Pirogoff's Amputation (1854). — In this oper- 
 ation all the foot is removed, except the 
 posterior part of the calcaneum, which, still 
 
 attached to the tendo Achillis and covered by the tissues of the heel, 
 is brought up and applied to the sawn surfaces of the tibia and fibula 
 (Fig. 167). The plantar flap is formed by cutting across the sole from 
 
 Fig. 166. — Stump thirty- 
 two years after Chopart 
 amputation (in 1877) by 
 the late Prof. Ashhurst. 
 Episcopal Hospital. 
 
212 
 
 AMPUTATinxS 
 
 just in front of the external malleolus to just below the internal 
 malleolus; the dorsal flap is slightly convex forward across the front 
 
 of the ankle-joint (¥i^. 168). The 
 malleoli are cleared, carefully pre- 
 serving the calcaneal branches of 
 the posterior tibial artery, and the 
 leg bones are sawed just above 
 the articular surface. The calcis is 
 sawed obliquely from above down- 
 ward and forward. This amputa- 
 tion preserves almost the normal 
 length of the extremity (lost in 
 Syme's amputation), but is diffi- 
 cult to perform, and makes a less 
 useful stump than Chopart's. 
 
 Many patients, especially labor- 
 ing men. prefer to have ampu- 
 
 FiG. 167. — Skiagraph of stump of Piro- 
 gofiF operation. (Case of Dr. H. C. 
 Deaver.) Episcopal Hospital. 
 
 Fig. 16S. — Skin incision for Pirogoflf's 
 amputation. 
 
 tation done at "the point of election" in the leg (a hand-breadth 
 below the tubercle of the tibia), instead of through the ankle or 
 lower leg, because the short stump is better adapted for use with the 
 cheaj) "peg leg." 
 
 Amputation of the Leg. — In the lower third of the leg, antero- 
 posterior flaps are to be preferred. Teale's method (1S58) produces 
 an excellent stump (Fig. loS). In the middle and upper leg the lateral 
 flap method of Sedillot (1840) as modified by J. Ashhurst, Jr. (1889), 
 is better: The knife is entered on the inner side of the spine of the 
 tibia, and passes downward for about three inches, then curves 
 backward, outlining a long flap and terminates diametrically opposite 
 the point of beginning; a short internal flap is then formed (Fig. 169). 
 The cicatrix is carried to the inner side of the stump, and the outer flap 
 covers the spine of the tibia (Fig. 170). If the skin on the front of the 
 leg is deficient, a long posterior flap may be used (Henry Lee, 1865), 
 preferabh- including onlv the gastrocnemius muscle (J. Ashhurst, 
 Jr., ISSlj. 
 
SPECIAL AMP VTA TIONS 
 
 213 
 
 Amputation at the Knee. A distinction is iujhIc hctwccn aiiipntji- 
 tions at the kncc-joiiit, which arc pure disarticuhitioiis, and ain]>n- 
 tations at the knee, in which a section is removed from the femoral 
 condyles. Two methods are in use, a long anterior flap method, and 
 a hiteral Haj) method; the hitter is more appHcable to disarticulations, 
 when the cicatrix falls between the condyles. But the anterior Hap 
 metlKxris I)(>tter c\-en in such cases. In disarticulations the i)atella 
 
 Fig. 170. — Stump of leg eight weeks 
 after amputation by Ashhurst's modifica- 
 tion of Sedillot's method. Episcopal 
 Hospital. 
 
 Fig. 169. — Amputation of leg by 
 long external and short internal flaps. 
 (.\shhurst's method.) 
 
 Fig. 171. — Stokes' osteoplastic supra- 
 condj'lar knee amputation, patella utilized : 
 shaded parts are those brought in apposi- 
 tion. (Farabeuf.) 
 
 should be retained if possible; or its articular surface may be removed 
 by a saw, and applied to the sawn surface of the femoral condyles 
 (transcondylar amputation of Gritti, 1857); or to that of the femoral 
 shaft (supracondylar amputation of Stokes, 1870) (Fig. 171). 
 
 Amputation of the Thigh. — The circular, modified circular, and 
 flap methods all produce an excellent stump in the thigh. The circular 
 is best whenever there is a choice. If flaps are used, the posterior 
 should be cut sufficiently long. The greater retraction of muscles 
 
214 
 
 AMPVTATIOXS 
 
 in the posterior flap carries the cicatrix away from tlie face of the 
 stump ' Fii:. 172). 
 
 Amputation at the Hip-joint ill. Thomson before 1777j. — Hemo- 
 stasis is secured by Wyeth's method (1890): Two steel pins are 
 used, each yg of an inch in diameter, and ten inches long; one pin 
 is introduced close to the spine of the pubis, and after traversincr the 
 adductor tendons emerges just below the tuberosity of the ischium; 
 the other pin enters below and within the anterior superior spine of 
 the ilium, traverses the gluteal muscles for about three inches, and 
 emerges well above the level of the great trochanter; the points of 
 the pins are immediately shielded by corks. A compress of gauze, 
 two inches thick and four inches square, is laid over the femoral 
 vessels at the brim of the pelvis, and an Esmarch band is wrapped 
 very tightly five or six times around the hip between the steel pins 
 and the pelvis (Fig. 173). 
 
 Fig. 172. — Ami>utation of right thigh Fig. 17.3. — Wyeth's pins, and Esmarch 
 
 (anterior-posterior flapsj. Episcopal band, for hemostasis during amputation at 
 Hospital. the hip-joint. 
 
 Antero-posterior Flap Method Guthrie. 1815). — The flaps are cut 
 from without inward, ^ with a moderately short knife; the posterior 
 is formed first, the incision commencing above the trochanter, and 
 crossing the back of the thigh in a curved line convex downward, to 
 a point in front of the tuber ischii; the anterior flap is then outlined, 
 extending at least five inches below the joint (Fig. 174). These flaps 
 being dissected up and the joint exposed, it is opened in front, the femur 
 being forcibly abducted and hyper-extended, bringing the ligamentum 
 teres into view; when this has been cut and the remainder of the 
 capsule divided, any fibres on the back of the joint are severed, and 
 the limb removed. 
 
 In cases where Wyeth's method of hemostasis is not available, 
 
 1 Guthrie cut them bv transfixion. 
 
SI'ECIA L A MI'UTA TIONfi 
 
 215 
 
 Mini \\luT(> M()inl)iir<,'"s iiu'tliod (see below) is not emi)I()yed, the siir- 
 jreoii iiiiiy ado])! either ])reliiniiiary lipition of the femoral vessels, 
 by ail anterior racket incision (Larrc\, iSlTj, o|)eniiiK the joint 
 from the front and (Jixidin^^ the remaining- tissues |)osteri«)rly from 
 within ontward;' or he may adopt DielVeiiijach's method (1827), 
 consistinjj of eireular ami)utation of the thigh followed by exeision 
 of the head of the femur through an outer longitudinal ineision;^ or 
 following lirashear's (1S()()) and Fourneaux-Jordan's (1879) method 
 as modified by Semi {\S[y.]) may first disarticulate through an external 
 incision and then, i)uneturiug the tissues on the inner side of the 
 thigh, introduce a double elastic tube, and comi)ress in this wax the 
 
 Fig. 174. — Incisions for amputation 
 at the hip-joint by antero-poterior 
 flaps. (Guthrie's method.) 
 
 Fig. 175. — Incision forinterilio-ahdominal 
 amputation 
 
 tissues of both anterior and posterior flaps before removing the limb. 
 Compression by a forceps tourniquet, somewhat like the forceps used 
 for intestinal anastomosis, may also be employed (Lynn Thomas, 
 1898). The mortality of hip-joint amputation is now about 8 per 
 cent, in disease, and 16 per cent, in traumatic cases (Wyeth, 1910), 
 this vast improvement in the results being due chiefly to improve- 
 ments in methods of hemostasis. 
 
 1 This is the "extirpation method" of Kocher, permitting careful dissection of 
 malignant disease, and clamping and ligating every vessel as it is cut. It also 
 permits nerve-blocking. 
 
 2 If there is nothin? to contraindicate subperiosteal excision, a more movable 
 stump will be obtained. 
 
216 AMPUTATIONS 
 
 Interilioabdominal Amputation (Billrotli, 1885). — The incisions 
 used are shown in Fig. 175. The horizontal and descending rami of 
 the pubes are divided, and the ilium is sawed through just in front 
 of the sacro-iliac joint, the entire intervening })()rtion of the pelvis 
 being removed. Ransohofi' (1909) has collected thirty-four cases of 
 this opei:9.tion, which is done almost solely for malignant disease; 
 only twelve patients survived more than a few hours. The best 
 method of hemostasis is Momburg's (1908), which has been used 
 by both Pagenstecher (1909) and Bier with success, in interiho- 
 abdominal amputations. This method of hemostasis had been em- 
 ployed up to 1909 wath success in over thirty operations of various 
 kinds. It consists in a])])lying an Esmarch band or thick rubber tube 
 (size of the finger) four or five times so tightly around the waist, 
 between costal arch and iUac crests, as to stop pulsation in both 
 femoral arteries; the band is applied only after the patient is anesthe- 
 tized, and before it is removed the patient is inverted and an elastic 
 band applied around the base of each lower extremity, so as to prevent 
 sudden anemia of the heart when the waist band is removed. 
 
CHArTKR IX. 
 
 EFFECTS OF IIFAT AND (OLD; INJURIES BY ELE(TPvIC 
 
 (I'UUENTS, LKillTNING, AND THE U()NT(;EX 
 
 RAYS; SKIN-GRAFTING AND JM.ASTIC 
 
 SURGERY. 
 
 Burns and Scalds. The effect is essentially the same whether 
 the injury is prodnced by flame (burn) or by hot li(ini(l (.s-mW). In 
 scalds, however, the hair nsnally remains intact, while in bnrns it 
 is singed. 
 
 Symptoms. — Local symptoms vary with the degree of heat and the 
 length of contact: mere singeing of the hair and a passing erythema 
 may be caused by momentary contact of flame, while prolonged 
 contact with some body at much lower temperature {e. g., hot water 
 bottle) may produce a very destructive lesion. Burns may be classi- 
 fied in three degrees: (1) Erythema. (2) Vesicles and Bullae. (3) 
 Sloughing. The reactionary changes wdiich occur in the burned part 
 are identical with those already discussed in the chapter on Infiam- 
 m at ion. 
 
 Fig. 176. — Scald of hand, second degree; twelve hours' duration; showing bullae. 
 Episcopal Hospital. 
 
 Constitutional effects of burns depend much more on the area 
 involved than on the depth of the burn. A superficial burn may be 
 attended by the gravest consequences, even death, if extensive; 
 whereas a very deep burn, if it involves only a small area, may be 
 almost unattended by constitutional symptoms. As in other injuries, 
 the constitutional effects of burns may be divided into those of shock 
 and reaction; and there usually follows, in severe cases, a stage of 
 exhaustion. The pain is intense, and in extensive burns ma\' induce 
 hyperpnea, which, according to the theory of Henderson (p. 172), 
 produces acapnia, and so induces shock; patients may die in the first 
 stage, without reaction. The unburned skin is pale, the patients 
 
218 
 
 EFFECTS OF HEAT AND COLD 
 
 feel chilly, and require to be covered up; the usual signs of shock 
 are present. Often, however, reaction begins soon, sometimes before 
 the patient is seen by the surgeon; and at this time yrosiraiion 
 icith excitement or irauinatic deliriniu (p. 173) may dominate the scene. 
 This stage lasts for a week or more, being accompanied l)y high 
 fever, often with intense congestion of organs underlying the lesion 
 (pneumonia, in thoracic burns; peritonitis, in those of the abdomen; 
 meningitis in those of the head). There is a tendency to fatty degener- 
 ation of all organs; the liver, spleen, and lymph nodes may be enlarged; 
 the urine is scanty, of high specific gravity, or entirely suppressed. 
 The bile is believed to be abnormally toxic. The blood is prone to 
 
 Fig. 177. — Ulcers resulting from exten- 
 sive burns received three months pre- 
 viously. Episcopal Hospital. 
 
 Fiu. 178. — Same patient, two months 
 later, after complete cicatrization. Epis- 
 copal Hospital. 
 
 thrombosis, and capillary embolism is not infreciuent; there is hyper- 
 leukocytosis and polycythemia; hemoglobinuria and albuminuria 
 may exist. In rare cases duodenal idceration (Curling, 1842), with 
 hemorrhage or perforation, develops, possibly from excretion of 
 toxic substances through Brunner's glands, or as the result of embo- 
 lism.^ The patient is excessively thirsty, but constantly vomits what 
 is taken into the stomach; there may be septic diarrhea; he feels 
 hot, is restless, and tosses off the bed-clothes. If he survives this 
 
 1 Alexander (1912) observed this complication in four out of twenty-seven 
 patients with extensive burns. 
 
liURNS AND fiCALDS 210 
 
 stafi;c, tlicre follows that of cxliaiistioii, with lu'ctic fever, profuse siip- 
 ])uratioii (►f the wounded surfaces, and |)(Tha])s metastatic (especially 
 subcutaneous) abscesses. 
 
 Death from Bums may be (hie to shock, to visceral complications, 
 to (wIkuisIIoii, or to Iwuioh/sis and aufo-iidoxicaiioii. Amouj^ the 
 visceral complications may be included edema of the glottis, from 
 inhalation of steam or hot smoke. In fatal cases, death usually 
 occurs within forty-eight hours. 
 
 Prognosis. In local burns prognosis as to life is good, even if the 
 part be much deformed by subsequent cicatricial contraction. Burns 
 of the trunk are more serious than those of the extremities. If a burn 
 in\()lves more than one-third of the body surface it usually is fatal. 
 (General burns are always fatal. Jiurns are i)articularly serious in 
 infants, the aged, those of intemperate habits, those with diseased 
 kidneys, etc. 
 
 Treatment. — The indications in all cases are to control the pain, 
 to coDihdt flic sliocli, and to prevent infection. In severe cases, where 
 death is antici])ate(l, the most that can be done is to ])romote euthan- 
 asia. This is best accomplished by the use of morphin hypodermic- 
 ally, and the immersion of the patient's body in a bath of saline 
 solution at about blood-heat. Shock is combated as described at 
 p. 17o; especially important is the dilution of the blood by saline 
 solution, which relieves toxemia and restores the fluid contents 
 depleted by discharges from the burned surfaces. Prevention of 
 infection involves local treatment of the lesions; anything which 
 protects them from the air lessens pain, and in extensive burns nothing 
 is so satisfactory as the continuous bath, which should be kept warm 
 and clean by frequent change. In burns of less extent it makes little 
 difference what dressing is applied, so long as it is aseptic, and absorbs 
 or does not dam up the discharges. Spray the burned surface lightly 
 with peroxide of hydrogen, and surgically cleanse the surrounding 
 parts. Do not scrub the burns. Open bullae w^ith a sterile knife, 
 and let the epidermis fall back in place as the serum escapes. Alex- 
 ander had occasion to treat twenty-seven burned patients simulta- 
 neously. He concluded that for burns of the first degree the picric 
 acid dressing was best; for those of the second degree he preferred 
 the boric acid solution bath, which was used for three hours at a 
 time, with intermission of six hours; and for burns of the third 
 degree he recommends the following ointment: ichthyol, gr. xlviii; 
 ol. olivse, foij; lanolin, q. s. ad ,^iij. Picric acid dressi)ig: gauze soaked 
 in 1 per cent, aqueous solution is laid on the burn and covered with 
 absorbent cotton, not with waxed paper, as evaporation should be 
 favored; the dressing is left in place four or five days. It should be 
 used only over small areas, as constitutional poisoning has occurred 
 (Rose, 1903). Senn's powder (boric acid, three parts; salicylic acid, 
 one part) or Billrotlis powder (equal parts of starch and zinc oxide) 
 may be applied to small burns, and forms a scab which need not be 
 removed for several days. Carron oil, made by stirring linseed oil 
 
220 
 
 EFFECTS OF HEAT AND COLD 
 
 and lime water into a thick paste, is very grateful to the ])atient. 
 So soon as granulations have formed, the burn is treated as an ordinary 
 ulcer (p. 54). 
 
 Fig. 179. — Sanio patient as Fig. 177, 
 one year later, after extensive plastic 
 operations. Episcopal Hospital. 
 
 Fig. 180. — Same patient one year after 
 complete cicatrization, showing result of 
 extensive plastic operations. Episcopal 
 Hospital. 
 
 When much skin has been destroyed, healing will be slow, and 
 skin-grafting should be employed. Amniotic membrane has given 
 
 some good results when grafted 
 on burns. A very large granulat- 
 ing surface should not be dressed 
 all at one time, for fear of ex- 
 hausting the patient; it is better 
 to dress half the burned area on 
 alternate days. If the patient is 
 kept in a hot room the burned 
 areas may be exposed to the air, 
 no dressing being employed. Great 
 care must be exercised by proper 
 use of splints, etc., especially in 
 burns about flexures of joints, to 
 prevent undue cicatricial contrac- 
 tion; but in some cases healing 
 
 Ik;, isi— Dffnnnity from burns of can be sccurcd Only as the result 
 
 feet. (Dr. \\liart(ju's case.) Children's >. i „^ /T7,- „ i '-'7 „.,J 
 
 Hospital. or such a process {b igs. 1 / / and 
 
F RUST-BITE 
 
 221 
 
 178), iind the (let'orinity must Ix* overcome hy siihsecnieiit pliistic 
 operations (Fij^s. 179 and ISO). In sexere grades of det'ormity, witli 
 paiiiliil sears which pre\ent conser\ative operations, amputation may 
 l)e necessary ( I*'i,<^. ISl ). 
 
 Effects of Cold. In many ways these" are anah)gous to those 
 ])ro(hiced hy heat, and (U'pend more on tlie hMi<^th of the exi)()sure 
 than on the intensity of tlie cold; moist cold, especially in a high 
 wind, is much more apt to ])roduce serious effects than a still, dry 
 cold. 
 
 Constitutional Effects. — Among predisposing causes are hunger, 
 fatigue, alcoholism, etc. There occur ])ainful sensations in the extremi- 
 ties, perhaps chills, followed by uncontrollable lassitude, somnolence, 
 coma, and death if the patient is not roused. The causes of death 
 are cerebral anemia (sudden and progressive chilling); cerebral con- 
 gestion (slow and continuous chilling); or embolism, in cases of sudden 
 reheating (Lebastard). Persoihs apjjarenfly dead should be kept in 
 a cool room, and treated by artificial respiration and gentle frictions 
 with evaporating or stimulating liniments; when reaction commences 
 (perliaj)s not for several hours), the temperature of the room may 
 be raised gradually, stimulants administered, and the patient wrapped 
 in blankets. Recovery has followed after being buried in the snow 
 for eight days (Tedenat), and when the rectal temperature had fallen 
 as low as 74.6° ¥. (Xicolaysen). 
 
 Fig. 182. — Frost-bite of second degree; duration, four days. Episcopal Hospital. 
 
 Frost-bite. — The local effect of cold is analogous to that of heat, 
 and may be classified in three similar degrees: Erythema, Bullae, 
 and Eschar, The exposed part, especially the fingers and toes, nose, 
 cheeks, ears, or the penis, becomes first the seat of congestion, attended 
 by some tingling and pain; soon, however, the part becomes blanched, 
 numb, and stiff", and to all appearances dead. This stage is well 
 exemplified when local anesthesia is produced by the ethyl chloride 
 spray. ^Yith proper treatment, the local destruction may go no 
 
222 EFFECTS OF ELECTRIC CURRENTS 
 
 further; if this is neglected, vesicles and bulUe form (Fifj. 182), and if 
 the cuticle is destroyed and infection follows, painful ulcers develop 
 which are long in healing. Finally, the freezing may be so intense 
 that a local slough, or gangrene of an entire limb may occur, the 
 larger arteries and veins being thrombosed. 
 
 Treatment of milder degrees of frost-bite consists in gentle frictions 
 with snow or iced water until sensation is restored; the part, which 
 now begins to tingle and burn, may next be painted with silver nitrate 
 solution (4 to 10 grains to the ounce), which allays these symptoms; 
 the part is then protected from injury and maintained at an even 
 temperature by absorbent cotton. When gangrene threatens, vertical 
 suspension of the limb should be adopted (v. Bergmann, 1873) with 
 immobilization by splints; as the swelling subsides the circulation 
 improves. The resulting sloughs are treated as advised in Chapter 
 II. Amputation should not be done until the line of demarcation 
 has been established. 
 
 Pernio or Chilblain is a vaso-motor disturbance of the skin following 
 previous frost-bite of mild degree. It develops as the result of sudden 
 variations in the temperature to which the part is exposed. Chilblains 
 occur in parts most exposed to frost-bite, and are especially common 
 in the anemic and run-down. A patient once affected- is prone to 
 have recurrence of chilblains on slight provocation. The symptoms 
 and treatment are much the same as for mild degrees of frost-bite. 
 Constitutional treatment should not be neglected. 
 
 Electric Currents. — These produce local effects (electric burns) 
 and general effects (electric shocks). The former are more severe 
 the less the area of contact, while severe shocks and milder burns 
 follow broader contacts. The burns do not differ from those due to 
 other causes, except in their extreme slowness in healing; Da Costa 
 (1910) warns against use of corrosive sublimate solutions as very 
 irritating. Skin-grafting usually is unsatisfactory, but a plastic opera- 
 tion may succeed. The constitutional eflfects of electric currents are 
 practically identical with those due to lightning strokes. 
 
 Lightning Strokes. — Death may l)e instantaneous. Stunning almost 
 always is produced, and burns frequently exist at the points of entrance 
 and exit of the current; they resemble burns due to electric currents; 
 arborescent marks, typical of lightning strokes, are attributed to 
 disorganization of blood in the vessels. Persons apparently dead 
 may recover after many hours; the usual condition of a patient just 
 after being struck by lightning resembles that seen in concussion of 
 the brain. Treatment consists in artificial respiration, external heat, 
 and other methods advised for shock (p. 175). 
 
 X-ray Dermatitis. — This affection, carefully studied by Codman 
 in 1902, is seldom seen except as the result of repeated and prolonged 
 exposure to the llontgen rays; before their danger was understood, 
 skiagraphers took no precautions to protect themselves from exposure, 
 and a dermatitis affecting the fingers was not unusual. The danger 
 to patients is extremely slight, especially since modern methods 
 
SKIN-GRAFTING 223 
 
 pcniiit vtTV sliort exposures. The dermatitis does not develop for 
 se\('ral da\s after exi)osure, and then is eharaeterized l)y sliji;ht 
 erythema, witli piii;mentation and exfoHation of ei)i(hTm; a severer 
 degree is evideneed hy the formation of vesicles and hiilhe, while 
 the third dej^ree involves a sloui,di of the entire skin. Eventually, 
 (lystro])Jues of the nails, keratoses, and ej)itheli<)inas may occur. 
 
 TrciitiiH'ut. — No further exi)osure should he allowed, even if the 
 patient thinks himself well protected hy leaden shields, etc. For 
 the intense ])ain which exists during the extremely slow casting of 
 the slough, alkaline astringents give the best results. Ointments are 
 said to favor carcinomatous changes (Leonard). When these occur, 
 am])utatiou is necessary. 
 
 Therapeutic Uses of the X-ray. — These should be applied by an 
 exi)ert Rontgenologist in consultation with a dermatologist. Some 
 cases of lu])us, a few of keloid, and occasionally a case of superficial 
 epithelioma may be cured, at least temporarily, by periodic exposure 
 to the .r-rays. Their action appears to consist in stimulating an 
 over-production of fibrous tissue, by which the growth of the cellular 
 elements is arrested or abolished. After operation- for carcinoma, and 
 in inoperable cases, systematic treatment with the .r-rays may delay 
 recurrence, diminish pain, and greatly promote the patient's comfort. 
 
 SKIN-GRAFTING. 
 
 In cases of extensive ulcers resulting from burns or other causes, 
 the practice of skin-grafting often not only accelerates healing, but 
 may be absolutely necessary to bring it about. For the grafts to 
 "take" well, it is essential that the granulating surface approach in 
 type to that of the "healthy ulcer" (p. 54). There are three principal 
 methods of skin-grafting, known by the names of Reverdin (1869), 
 Thiersch (1874), and Wolfe (LS75), or Krause (1893). In all of these 
 methods the granulating surfaces must first be ijreparcd for the recep- 
 tion of the grafts. Roberts (1909) recommends dressing the part 
 for several days previous to the grafting operation with gauze soaked 
 in formaldehyde solution (1 to 200); this renders it sterile, and the 
 tops of the hardened granulations are then gently scraped off with a 
 sharp razor, just before applying the grafts. The ulcer is then washed 
 with sterile saline solution to remove the antiseptics. The slight 
 bleeding is checked with pressure by sterile gauze. The best sites 
 from which to obtain grafts are the adductor surfaces of the thigh, 
 the inner surfaces of the upper arms, and the lateral abdominal and 
 thoracic walls; hairy skin is not suitable for grafting, as, apart from 
 the deformity which might result from reproduction of the hair, 
 it is difficult to sterilize and less apt to grow successfully than more 
 delicately formed skin. The region from which the grafts are taken 
 also must be prepared as for an aseptic operation. Antiseptic methods 
 are not successful. 
 
224 
 
 SKIN-GRAFTING 
 
 Reverdin's Method. — Minute particles of the cuticle are raised 
 on the point of a needle, cut off with a sharp scalpel, and at once 
 transferred to the granulating surface, previously prepared. As 
 many such grafts as may be required (a score or more) are a])plied 
 over the ulcer, with the epidermic side upward, at close intervals; 
 gently pressed down on the granulations, and held in place by strips 
 of rubber tissue; space should be left between the rubber strips, to 
 permit escape of discharges, and these are absorbed in sterile gauze 
 dressings held in place by a. light bandage. The part is suitably 
 splinted, and need not be dressed for four or five days, when it will 
 be found that many of the grafts have taken, and may be recognized 
 as minute islets of bluish-white epiderm growing in the centre of the 
 granulating area (Fig. 183). In time these islets coalesce, and a number 
 of small ulcers surrounded by epiderm replace the one large surface. 
 
 Fig. 183. — Skin-grafting by Reverdin's method, in a case of burns of leg. The white 
 spots on the surfaces of the ulcers are islets of new-formed skin. Episcopal Hospital. 
 
 Thiersch's Method. — Long strips of epiderm, with only the most 
 superficial layer of the cutis, are cut by means of a ^'ery sharp razor, 
 with a rapid sawing motion, while the skin is held taut. The skin 
 and the razor should be moistened with saline solution, to facilitate 
 the process. The long grafts are then at once transferred to the 
 granulating surface, pre^'iously prepared, and spread in place, covering 
 nearly its entire surface. Dressing is similar to that for the Reverdin 
 method. Thiersch grafts are more difficult to cut, require a general 
 anesthetic, and are less apt to grow than the smaller grafts of Rever- 
 din; but if they do grow, the healing of the ulcer is very much more 
 rapid, and the resulting scar less conspicuous. 
 
 Fig. 184. — Ulcer from compound fracture. Wolfe skin-grafts from amputated leg. 
 
 Episcopal Hospital. 
 
PLASTIC SURdEHY 225 
 
 Wolfe-Krause Method. Tlu' iMitire thickness of the skin is trans- 
 planted, l)nt witliont any snhentaneons tissue. Tlie j^ral'ts may he 
 ohtained from the i)atient's own hody, or from the health\' tissues 
 of a recently amputated hmh. As a rule, pieces an inch in diameter 
 are large enoujjh, leaving space for discharges from the ulcer (Fig. 
 184). The entire operation should he dry, and al)solutel\- asej)tic. 
 Wolfe grafts may also he applied to the wound at the time of oper- 
 ation, and are i)referal)le for such use to Thiersch grafts, which latter 
 are hetter suited for apjilication to granulating surfaces. 
 
 PLASTIC SURGERY. 
 
 The object of plastic surgery {anaplastii) is to restore or to improve 
 the function or appearance of a part, deficient congenitally, or through 
 disease or injury, lentil within a few^ years its field was limited to 
 the skin and subcutaneous tissues (including mucous mem})ranes), 
 but recently the formation of new joints (p. 471), transplantation 
 of bone (p. 504), etc., have been done. Cinematoplastic amputations 
 (p. 202) and prosthesis by subcutaneous use of paraffin (p. G20) are 
 parts of plastic surgery, as are certain operations on the female 
 perineum and vagina (Chapter XXIX). Its more limited field alone 
 will be discussed here. 
 
 The operation consists essentially in shifting flaps of skin and 
 subcutaneous tissue, attached by one or more pedicles, so as to cover 
 in defects left by excision of morbid structures. Such operations will 
 not succeed unless asepsis is maintained, and unless no active disease 
 exists in the parts on which the operation is done. Lupus and 
 syphilitic ulcerations must be healed, and the disintegrating process 
 at a standstill before any plastic surgery is attempted. Another 
 maxim of extreme importance in plastic surgery is to do too little 
 rather than too much at each step of the operation, which is thus 
 often better divided into several sittings. 
 
 Plastic operations may be classified as follows: 
 
 1. Anaplasty by simple approximation, as after excison of any 
 tumor in which the wound edges can be brought together; in the 
 operation for hare-lip, etc. 
 
 2. Anaplasty by transfer of flaps from the immediate neighborhood, 
 by gliding, stretching, etc., as in operations for deforming cicatrices 
 from burns, and in the Indian method of rhinoplasty (p. (V21). 
 
 3. Anaplasty by transfer of flaps from a distance: 
 
 (a) Bv o?ie migration, as in the Italian method of rhinoplastv 
 (p. 621)- 
 
 (b) By successive migrations (method of Roux), as from the abdomen 
 to the arm, and then from the arm to the face. 
 
 4. Anaplasty by readjustment of totally severed parts, including skin- 
 grafting, transplantation of bones, joints, etc. 
 
 The simpler the operation the more successful it is likely to be; 
 hence the simpler methods always should be tried first, unless mani- 
 15 
 
226 PLASTIC SURGERY 
 
 festly inadequate. Cicatricial tissue usually should be excised and 
 not employed in plastic surgery, as it is very apt to slough. Occa- 
 sionally, however, where a fold of cicatricial tissue exists (as in the 
 knee or elbow) it will be possible to split it, forming two flaps; and 
 if the splitting be done by a Z-shaped incision, on straightening the 
 limb two lax flaps will be available to cover in the flexure of the 
 joint. In all plastic operations great gentleness should be used in 
 manipulation; strict hemostasis by the finest ligatures must be secured; 
 and accurate, but not too tight coaptation must be procured. The 
 flaps should contain a moderate amount of subcutaneous tissue and 
 their bases should be broad and should contain the main vascular 
 supply; and the flaps should be made of sufficient size, especially 
 when cut from tissues naturally lax (neck, scrotum), as in them 
 retraction is greatest. When flaps are transferred from a distance, 
 or when the base of the flap is much twisted in adjustment, the base 
 must be divided (to restore contour) in from one to three weeks after 
 the first stage of the operation. 
 
 Diagrams illustrating the commoner varieties of plastic operations 
 are given in Chapter XIX. 
 
CHAPTER X. 
 SURGEin' OF THE BLOOD VASCULAR SYSTEAL 
 
 Hemorrhage. This is tlic natural couscciiu'iicc of injuries which 
 sever the walls of bloodvessels. Hemorrhage may l)e apparent, 
 when it occurs in an open wound; or concealed {internal), when it 
 takes place into one of the natural cavities of the body. Suhndaneous 
 hemorrhagic attended l)y extravasation or formation of a hematoma, 
 has i)een mentioned at p. HiO. 
 
 The signs of hemorrhage are both local and constitntional . The 
 local signs of venous and arterial hemorrhage are different, but the 
 constitutional signs are identical. Venous hemorrhage is characterized 
 by the darker, bluish color of the blood; by its flowing in a steady 
 stream, not in spurts; and in most cases of wounds of the extremities 
 by the ease with which it is arrested simply by elevation of the part. 
 .Arterial hemorrhage occurs in rhythmic jets, and the blood usually 
 is of a distinctly redder tinge. 
 
 Constitutional Signs of Hemorrhage. — As the \olume of blood within 
 the vascular channels is rapidly lessened by hemorrhage, the heart 
 begins automatically to pulsate more quickly. A steady rise in the 
 pulse rate is one of the surest signs of hemorrhage. As the quantity 
 of blood in the system decreases, faintness comes on: there is thirst, 
 rapid and sighing respiration (air-hunger); the skin becomes blanched 
 and clammy; the lips and conjunctivae are pale; the ears ring; vision 
 fails; specks and blackness float before the eyes; restlessness and 
 delirium come on; involuntary dejections may occur; and with one 
 or two gasps the patient may seem dead. At this stage bleeding 
 may cease spontaneously, owing to the diminished force of the circula- 
 tion which permits thrombosis; but it may begin again when reaction 
 sets in. After very severe or repeated hemorrhages, faintness is 
 prone to recur; and the patient may be feverish and delirious for 
 several days. Slow hemorrhage is much less serious than profuse, 
 sudden bleeding. Patients in early adult life bear hemorrhage better 
 than infants or the very old; and, as a rule, women bear it better 
 than men. 
 
 Hemophilia is the name given to an obscure condition affecting 
 males almost exclusively, and seemingly transmitted from one gener- 
 ation to another only through the female sex. It is characterized by 
 an abnormal and inveterate tendency to hemorrhage even from the 
 most trifling injuries. Mere scratches, the extraction of a tooth, 
 etc., frequently have caused such persons to bleed to death. The 
 vice appears to reside in a loss of coagulability of the blood, though 
 
228 SURGERY OF THE BLOOD VASCULAR SYSTEM 
 
 it was long held that the bloodvessel walls were at fault. Blood 
 oozes in profusion from the capillaries, and no local remedies are of 
 much avail. The internal administration of calcium chloride may 
 be tried; and the hypodermic injection of horse or rabbit serum, and 
 even of diphtheria antitoxin has been used in some cases with benefit. 
 Nolf and Herry (1910) secured arrest of the bleeding in nine cases 
 by a single hypodermic injection of 10 c.c. of a 5 per cent, solution 
 of peptone in 0.5 per cent, sodium chloride solution. This can be 
 sterilized by boiling. Hypodermoclysis, intravenous injections of 
 saline solution, and even direct transfusion of blood may be tried. 
 Plate II, Fig. 2, shows the subcutaneous hemorrhages which followed 
 the insertion of needles for hypodermoclysis in a patient with hemo- 
 philia following circumcision; in this case recovery occurred after the 
 direct transfusion of blood and use of diphtheria antitoxin. Yet a 
 year later the patient was again in the ward with hemarthrosis (p. 
 387) following a trifling contusion of the knee. 
 
 Spontaneous Arrest of Hemorrhage. — As mentioned above, bleeding 
 sometimes ceases spontaneously. IMost very small vessels cease to 
 bleed in a few minutes. In the case of capillaries, swelling of the 
 endothelium occludes the lumen; in larger vessels there occur in 
 addition contraction and retraction of the vessel walls. Contraction 
 of a divided vessel is said to be an effort to restore the blood pres- 
 sure to normal. Retraction results from the natural elasticity of the 
 vessel, its ends being drawn back among the tissues, and its walls 
 curling upon themselves so as to diminish the lumen, thus favoring 
 coagulation. 
 
 Treatment of Hemorrhage. — Temporary control of hemorrhage 
 usually can be secured by direct pressure against the bleeding point, 
 or on the main vessel of the part close above the wound, with eleva- 
 tion of the wounded part. When possible a tourniquet or Esmarch 
 band (p. 193) can be applied. For permanent control of hemorrhage 
 the surgeon has many means at his command. 
 
 1. Position. — Elevation of the part has been mentioned already, 
 and should never be neglected. It is a remedy so simple that it 
 often is overlooked. Hold the wounded extremity up in the air until 
 help arrives, if you can't do anything else. 
 
 2. Pressure. — Direct pressure on the wounded vessel always can 
 be relied on to check hemorrhage. Use your finger if you have noth- 
 ing else. A graduated compress may be held against the wounded 
 vessel: this is made of pieces of gauze so cut as to form a pyramid 
 when placed one on the other; the apex of the pyramid is placed 
 against the wounded ^'essel, and the compress is held in place by a 
 tight bandage. Hyperflexion of the elbow or knee over a compress 
 will control bleeding below. Hemostatic forceps (Fig. 140) or other 
 form of clamp may be applied directly to the wounded vessel, and 
 in emergency the forceps may be left in place thirty-six to forty- 
 eight hours. If the wound in the vessel cannot be found, com- 
 press the main artery, when possible, at a higher point. This, and 
 
PLATE II 
 
 Fig. 1. — Multiple nevi, affecting scalp, forehead, left foot, etc., in a baby aged 
 Si^nnonths. Episcopal Hospital. 
 
 Fig. 2. — Hemophilia, two days after circumcision, in a boy aged 8 years; shovving 
 subcutaneous hemorrhages; that in right thigh followed an attempt to give hypo- 
 dermoclysis. Episcopal Hospital. 
 
TliKATMEST OF IIKMORUII ACE 229 
 
 elevation of the ])art, will arrest, temporarily, any heiiiorrliaf^c. Or 
 the woiiiul ina\' he packed with ^aiize or lint. Acupressure, (Sir .1. Y. 
 Siinj)soii, IS.');)) is seldom emj)loyed at i)resent. A lonj^ and strong; 
 steel pin is j)assed under the \essel, o('chidin<i: it a<;ainst the overlying 
 tissues, as the stem of a flower is pimied against the eoat lapel; or a 
 ligature in figure-of-eight fashion may be wound around the two ends 
 of the pin. compressing the vessel between the pin and the intervening 
 tissues. Farci pressure or (incieiofrip.si/ consists in occluding the bleeding 
 \essels by powerful clamps which are remo\ed at once; they eause a 
 reactive inlhunmation which will occlude the lumen. Skene (1897) 
 and A. J. Downes (1902) used an electro-thermic angeiotribe. 
 
 o. IIkat and Cold are efficient in hemorrhage of mild degree. 
 Cloths wrung out of very hot water (120° F.) applied to the face of 
 an oozing wound (p. 190) usually check all cai)illary bleeding. Cold, 
 in the form of ice caps, frequently is employed in gastric and intestinal 
 hemorrhage; and often is of value in checking extravasation in the 
 subcutaneous tissues. The actual cautery, heated to a black heat 
 only, is very efficient when other methods are not available. 
 
 4. Styptics are seldom used except for oozing. Alcohol is not 
 very active. Alum, tannic acid, the perchloride and persulphate of 
 iron, etc., are more valuable, especially when applied on a graduated 
 compress. Cocain and epinephrin are employed on mucous mem- 
 branes. 
 
 5. Torsion. — A bleeding vessel may be caught in forceps and 
 twisted on itself until the forceps is twisted off ("free torsion";; or, 
 being caught higher up by one forceps, may be twisted by another 
 ("limited torsion"). In either- case the manoeuvre succeeds in ap- 
 proximating the walls of the vessel and in arousing sufficient reaction 
 on the part of the intima to favor permanent occlusion. Vessels of 
 moderate size only should be treated by torsion; usually from five 
 to six turns are sufficient. 
 
 6. Ligation. — Ligatures, like sutures, are of absorbable or non- 
 absorbable material. Lsually catgut ligatures are preferred, and 
 for large vessels chromicized catgut is used, though some surgeons 
 prefer silk or linen. \Yhen a ligature is applied to a vessel it constricts 
 it concentrically, crumpling its coats more or less, and bringing 
 intima into contact with intima; owing to the properties of this 
 serous surface, like that of the peritoneum, pleura, etc., prolonged 
 contact after \'ery moderate injury is sufficient to secure firm adhesion. 
 It is not usually necessary to draw the ligature so tight as to rupture 
 the inner and middle coats; it is sufficient to occlude the vessel. 
 The method of union after firm apposition of the intima is patholog- 
 ically identical with that already described in connection with the 
 repair of wounds as union by adhesion. The walls of the vessel, 
 with their endothelial cells, play a more important part in the process 
 than the contained blood; indeed, it is denied by some pathologists 
 that the blood takes any part in the process. The formation of a 
 clot is not a necessary phenomenon, and if infection be absent firm 
 
23() SURGERY OF THE HLOOh VASCULAR SYSTEM 
 
 occlusion of vessels will rxcur without any thrombosis; this renders 
 it safe (Guyon, 18(f>8; Wyeth, 1876j, though not always expe/lient, 
 to ligate large trunks close to the origin of branches, or tice versa. 
 Usually, however, a clot forms proximal to the ligature, and, if the 
 vessel has been tierl in its continuity ii. e., in cases where the vessel 
 has not been divided j, a smaller clot usually forms on its distal side. 
 These clots lie rather loosely in the channel, and are gradually con- 
 verted into fibrous connective tissue by organization (p. '40). Should 
 such a clot extend from the point of ligation past the origin of a large 
 branch, there might be danger of emboli being carrie^^l away from it; 
 hence it usually is considered proper not to apply a ligature within 
 an inch or so of a large branch. 
 
 Rule^ for Ligation of Wounded Arteries. — ^These rules are now classic 
 in surger>-, and even today admit of verj- few exceptions: 
 
 1. In cases of primary hemorrhage do not ligate the vessel unless it is 
 actually bleeding at the time. This rule applies to primarj', not to 
 secondary' hemorrhage, and should be obserxed because: (a) bleeding 
 may never recur; ib) it Is difficult to know which arter>- to tie unless 
 the surgeon sees it bleed; and (c) search for the artery' may cause 
 unnecessary' damage and lead to infection. Exceptions: (a) if the 
 arterj' is seen pulsating in the wound it should be tied whether it 
 bleeds or not: the operation is easy, harmless, and the remedy siu-e; 
 (6) if the patient has to be transported a long distance or will be out 
 of reach of a skilful surgeon, it will be proper to make a search for 
 the vessel even if it is not bleeding nor easily found. 
 
 2. The vessel should be ligated where it bleeds and not elseichere, 
 no matter what the condition of the wound. Because: (a) unless the 
 wounded vessel itself Is seen, the surgeon may ligate the wrong vessel 
 and fail to check the bleeding; (6) ligation even of the proper vessel 
 at a higher point will not prevent recurrence of bleeding from the 
 distal end, nor from the proximal end if a large branch intenenes, 
 so soon as the collateral circulation is established. There are no 
 exceptions to this rule (Guthrie, 1815; Matas, 1909j. But in certain 
 regions (floor of the mouth, pehis) it may be necessarj' to expose 
 the bleeding point by a counter-incision, instead of through the 
 original wound. 
 
 3. Both ends of the wounded vessel should be ligated; and if it is 
 only partly severed a ligature should be applied each side of the wound 
 and the artery then divided between them. Because: when collateral 
 circulation develops bleerJing from the distal end will occur even if 
 this is not bleeding when the proximal is ligated. Exceptions: (a) 
 when the distal end cannot be found, the wound should Ix* packed 
 after ligation of the proximal end ; and (b) where both ends are easily 
 found, where the injurj- was a clean incised wound, and where occlu- 
 sion of the the vessel might cause gangrene, an attempt at circular 
 arteriorrhaphy (p. 234) should be made. 
 
 4. Wound of a large vessel near its origin requires ligation of the 
 wounded vessel below the wourul, and of the parent trunk above and 
 
TliF.ATMKSr or IIKMOiaHIMiE I'.W 
 
 hcliiir the orifiln of the icunudcd hnnicli ( I'Mu'. IS')); mikI iroinid of a 
 main irunk ucar ilw orujin of <i Uirijc hrancli ni/iurr.s- Ikju'ioii of the 
 icoiindrd vcssfl (ihorc mid ht'loir Ilw iroiiiid itiid iKjdIion of Ihc Idrf/c 
 hraurh (Fig. ISli). Htcdiisc: in the lormcr case tlic end ol" tl)e 
 bleeding vessel next the main trnnk is too short to hold a ligature; 
 and in the second ease the estahlishnient of collateral circulati<»n 
 will cause the branch to bleed through the wound of the main trnnk 
 unless the branch is ligated. Exec ))i ion: in case of the main vessels 
 (carotid, iliac, femoral, popliteal), occlusion of which may cause 
 gangrene, the wound in the main trunk should be sutured, and only 
 the collateral should l)e ligated. 
 
 Fkj. IS.j. — \\'oun(l of ;i largo liranch noar 
 its (laroiit trunk rtMiuircs lifiatiDii of the 
 trunk above and below the branch as well 
 as of the liranch. 
 
 Fig. l.Sti. — Wound of a main trunk 
 near theori^jin of a large Ijranch recjuires 
 ligation of the branch as well as of the 
 trunk. 
 
 Mtiliod of Ligating Arteries. — Arteries (and veins) may be ligated 
 in continuity or at the seat of the lesion. In the latter case, the 
 cut end is grasped with a hemostat, drawai slightly out of its sheath 
 and the ligature applied well above the forcejjs. When ligation is 
 done in contiiuiity, an incision is made slightly oblique to the known 
 course of the vessel, the proper muscular interspace is found, and 
 when the sheath of the artery is exposed, it is picked up by forceps 
 and cautiously divided by the edge of the knife cutting toward the 
 forceps (Fig. 187). The threaded aneurysm needle is then gently 
 insinuated between the artery and its sheath (entering on the side 
 where lies the most dangerous structure, usually a vein),^ and is 
 gradually teased around the artery, great care being exercised not 
 to separate the sheath more extensively from the vessel than is 
 absolutely necessary and not to include a neighboring nerve in the 
 ligature. When the point of the aneurysm needle emerges on the 
 opposite side of the artery, the loop of the ligature lying in the con- 
 cavity of the needle is caught in forceps and pulled through (Fig. 187). 
 Then the aneurysm needle is withdrawn. An assistant then feels 
 for the pulsation of the artery or its main branches below, and the 
 surgeon temporarily constricts the artery between the ligature and 
 
 ' Venae coniifos may bo tied in with their artery. 
 
232 
 
 surgehy of the blood vascular system 
 
 his finger, determining whether lie is about to tie the proper vessel 
 by its effect on the pulse below. In the case of anomalous high 
 division of the brachial artery, for instance, he might be tying only 
 one branch instead of the main trunk, as desired; and unless obliter- 
 ation of the radial and ulnar i)ulse was 
 sought for, his error might pass undis- 
 covered at the time. Arteries of ordi- 
 nary size are to be tied with the square 
 knot (Fig. 114); very large arteries 
 (innominate, iliac, femoral) or those 
 which are atheromatous, are more 
 safely secured by the stay knot of 
 Ballance and Pxlmunds (Fig. 188). 
 
 Fig. 187. — Ligation of an artery; 
 above, the sheath is being opened; in 
 the centre, the ligature is being 
 passed; below, it is being tied. 
 
 Fig. 188. — The stay-knot. A, double ligature 
 passed and each end tied separately; B, all four 
 ends tied as if they formed one ligature. 
 
 Secondary Hemorrhage. — This was defined and its causes stated at 
 p. 1 77. It is apt to come from the distal stump of a vessel ligated in con- 
 tinuity, and is frequently ushered in by slight blood-stained discharges, 
 premonitory of the violent gush when the ^■essel finally gives way. 
 
 Treatment. — The treatment differs in some respects from that 
 proper for primary hemorrhage. The first rule given above does 
 not apply, because hemorrhage having once recurred is extremely 
 liable to do so again unless active measures are instituted. The 
 surgeon may after the first, and must after the second bleeding adopt 
 determined measures to prevent a return of the hemorrhage (Erich- 
 sen, 1861), and should ligate both ends of the wounded artery in the 
 wound, no matter what the condition of that icound, whether or not active 
 bleeding is present ichen the operation is undertaken. Should re-ligation 
 be impossible (as in vessels at the root of the neck, or in the pelvis), 
 a graduated compress may be applied; or neighboring collaterals 
 may be ligated, to check the return circulation (e. f/., the vertebral 
 in secondary hemorrhage after ligation of innominate.)^ If secondary 
 hemorrhage recurs after re-ligation in continuity, amputation should 
 be done at the site of ligature in the lower extremity; while in the 
 upper extremity this final step sometimes may be obviated by ligating 
 
 1 Secondary hemorrhage recurring from an amputation stump requires re-ampu- 
 tation if ligation of the main trunk of the limb has failed. 
 
WOUNDS or nLOODVESSELS 
 
 233 
 
 tlic main vessel (hnicliial, axillary, or suhclaxiaii) at a hi<fher point. 
 Ill the lower extremity such a course would surely cause gangrene, 
 so amputation is better. 
 
 Constitutional Treatment of Hemorrhage. — This is very much the 
 same as that for shock (|). 17.")), csjx'cjally \ahial)le l)eiii<f ele\'ation 
 of the pelvis and lower extremities, autotranst'usion, intravenous 
 saline infusion, direct transfusion of hlood, and the administration 
 of cardiac stimulants. 
 
 Subcutaneous Injuries of Bloodvessels. Injuries of either arteries 
 or \-cins are attciuh'd hy rcactixc phenomena which correspond 
 l)athologicalIy to the inflammatory process. In cases of contusion 
 this reaction may cause thrombosis of the hlood within the vessels; 
 hut far more frequently the vessel is ruptured suhcutaneously, caus- 
 ing; the formation of a hematoma (p. loD). This may he absorbed 
 if small, but sometimes remains fluid, may become infected (through 
 the blood-stream, from a neighboring viscus, or from the deeper 
 skin cocci), and recpiire opening and drainage. If a hematoma pro- 
 gressively increases in size after its formation, it is probable that a 
 
 Fig. ls'.t.--( laiiLn-ciic t'MiiMwu 
 ill Hunter's caiia 
 
 atidii of lidtli cndsuf niijturc(l fi'inoral aitcry and vein, 
 Aniimtation. Keeovfij-. Eiiiscojjal Hos^jiital. 
 
 large vessel is ruptured; it will then be proper to open the hematoma 
 and check the hemorrhage. A hematoma due to rupture of a large 
 vessel may cease to grow and finally become encysted, still being 
 in commimication with the source of hemorrhage: if this was a vein, 
 a so-called venous aneurysm is formed; if an artery, a circumscribed 
 traumatic aneurysm. A diffused traumatic aneurysm is more frequent 
 in the axilla or groin, where the tissues are more readily separated 
 by the extravasated blood; the blood in such cases is more apt to 
 become clotted, and may very seriously compromise the circulation 
 of the limb. The semi-clotted mass should be evacuated, and the 
 ruptured vessels ligated. Fig. 189 shows gangrene following ligation 
 of both ends of a ruptured femoral artery and vein, due to contusion 
 by a heavy steel plate, and accompanied by the formation of an 
 immense diffuse traumatic aneurysm. 
 
 Open Wounds of Bloodvessels. — These may be incised, punctured, 
 etc., or due to gunshot injury. If smaller vessels have not been 
 divided completely by the original injury, the surgeon should cut 
 
234 
 
 SURGERY OF THE HLOOI) VAHCVLAR SYSTEM 
 
 them entirely across, and ligate both ends. For punctured wounds 
 of the hirijer veins a lateral lifjature should be aj)plied (Fif^. 11)0); 
 by brin_(,niin intima into contact with intinia, firm union without 
 thrombosis may be expected. If a large vessel, artery or vein, presents 
 an incised wound, and obliteration of the circulation by ligature is 
 likely to result in gangrene (as is especially the case in the popliteal, 
 femoral, and axillary arteries), attempt should be made to suture 
 the wound in such a way as to evert its edges, thus apposing serous 
 
 Fig. 190. — Application of a 
 lateral ligature for puncturecl 
 wound of vein. 
 
 Fig. 191. — Circular arteriorrhaphy by Carrel's 
 method: when the three stay sutures are pulled taut, 
 the introduction of the sutures is much facilitated. 
 
 surfaces. Should such a vessel, especially an artery, be completely 
 divided, circular arteriorrhaphy should be done fFig. 191), using a very 
 fine round-pointed needle and No. 500 silk, soaked in sterile vaselin 
 (Carrel, 1902). The circulation is controlled by Crile's clamps (Fig. 192), 
 applied directly to the wounded vessel. Even if thrombosis follows 
 the attempt, occlusion of the artery will be so gradual that gangrene 
 will be much less apt to ensue than after ligation. Should ligation 
 
 Fig. 192. — Crile's clamp for temporary occlusion of bloodvessels, blades 
 covered with rubber. 
 
 of the main vein of a limb be necessary, the main artery should not 
 be ligated also; to do so increases the risk of gangrene. According 
 to Wolff's statistics (1908), gangrene occurred in 34 per cent, of cases 
 where both femoral artery and vein were ligated, and in only 8 per 
 cent, where the femoral vein alone was ligated. Gumhot and other 
 contused wounds rarely admit of suture. 
 
 Entrance of air into veins is no longer regarded as a frightful 
 calamity, presaging immediate death. In operating at the root of 
 
M'or.\7).s' OF iiLnnn\p:ssELs 
 
 LM.) 
 
 the neck, wIktc lu'j^ativr pressure in tlie \'eiiis (liiriii<!; iiisjjiratioii is 
 most iimrked, air may l)e sucked into the circulation, and when in 
 hirge f|uantity has, in a few instances, Keen prochictive of serious 
 conse(|nenees. A suckinu', lap])in<,', or ic'iruhnt; sound is heard, eh)seiy 
 folh)\\ini; a •;usli of hlood from the wounded vein, and sometimes 
 foHowed l)y the apj)earanee of frothy l)Io()d in the wound.' Pale- 
 ness and Hvidity, faihire of the cireuhition and colhipse may ensue. 
 In a patient uuik'r my own care (19()S), in Dr. Frazier's serviee at 
 the Kpisco])al Hospital, no symptoms wliatever were produced, 
 tliouijli tlie sucking sound of air entering the vein (branch eh)se to 
 subclavian) was very pronouneed. In operations in the "danger 
 zone" the surgeon if ])ossible should apply a compress to the region 
 where the internal jugular and subcUnian veins unite, thus causing 
 back pressure on the main trunks above; this facilitates dissection. 
 When the accident occurs, plug the opening with the finger until 
 otiier means of arresting the hemorrhage can be applied. 
 
 Fig. 193. — Aneurysmal vaiix (or direct 
 arterio-venous fistula). 
 
 Fig. 194. — Varicose aneurysm (or indirect 
 arterio-venous fistula). 
 
 Arterio-venous wounds occasionally occur from puncture, stab, 
 or gunshot injury involving both artery and vein. The superficial 
 parts may heal, leaving a form of traumatic arterio-venous aneurysm: 
 if the artery and vein are in direct communication, the condition 
 is known as aneurysmal vari.r (Fig. 193); if a sac intervenes, it is a 
 varicose aneurysm (Fig. 194).- The diagnosis in either case depends 
 on the history of injury, and the rather tardy development of signs 
 of a traumatic aneurysm, accompanied by a susurrus, or purring 
 thrill, and in the case of a varicose aneurysm by a distinct impulse 
 and aneurysmal whirr. The buzzing is continuous, not disappear- 
 ing entirely during diastole (except sometimes when the limb is 
 elevated — Xelaton), but being accentuated during systole; the 
 murmur is transmitted centrifugally, sometimes centripetally, and 
 
 ^ A .somewhat similar .sound, but no bleeding, follow.s injury of the pleura. 
 -The terminology of John B. Roberts {arterio-venuus fistula, director indirect) is 
 preferable. 
 
236 SURGERY OF THE BLOOD VASCULAR SYSTEM 
 
 the superficial veins may pulsate (Matas). An aneurysmal varix 
 rarely gives much distress, except for the buzzing sensation on palpa- 
 tion; this may be audible to the patient; but the tumor seldom 
 enlarges, and, as a rule, only palliative treatment is required. If 
 necessary, however, the surgeon may attempt separation of the 
 vessels and suture or ligation of the defects. A varicose aneurysm, 
 on the other hand, is prone to grow larger progressively, and, though 
 rarely reaching very large size, in many respects resembles an ordinary 
 aneurysm. Operation generally is indicated; this may consist 'merely 
 in ligation of the more accessible vessel (preferably the artery) above 
 and below the sac, or in extirpation of the sac and suture of the venous 
 and arterial orifices; better still (Bickham, 1904), would be oblitera- 
 tion of the sac by endoaneurysmorrhaphy (p. 257). For the success 
 of most of these methods, preliminary control of the circulation is 
 necessary; where this is impossible the surgeon must open the sac, 
 plug the arterial orifice with his finger, and apply a suture to occlude 
 the orifice as quickly as possible; the venous opening is next closed. 
 
 Injuries of the Heart. — Rupture. — Rupture of the heart may be due 
 to injury or disease. Blood is pumped into the pericardium, causing 
 embarrassment of cardiac action, with dyspnea, cyanosis, collapse, 
 and death, before suture of the rent, which is indicated, can be 
 attempted. 
 
 Wounds. — Wounds of the heart are usually stab or gunshot wounds. 
 In cases coming to operation, the left ventricle is most often wounded, 
 generally on the left of the sternum. The symptoms are much the 
 same as those of rupture of the heart, though somewhat less severe; 
 if the patient does not die within a few minutes, he usually survives 
 several hours, aftording opportunity for rational treatment. Wounds 
 of the pleura (40 to 70 per cent.) and of the lung (30 to 50 per cent.), 
 may coexist, and pericardial hemorrhage may come from this source, 
 and not from a wound of the heart itself. In all cases in which 
 cardiac injury is suspected, however, exploratory pericardiotomy 
 should be done. Where no precordial wound exists, Matas advises 
 an oblique incision, from the mid sternum opposite the fourth inter- 
 space, downward and toward the left, dividing the fifth or sixth 
 costal cartilage, which is excised. When an external wound makes 
 the diagnosis more certain, Spangaro's incision (19()()) in the fourth 
 intercostal space is preferable; this extends from the left margin of 
 the sternum out as far as necessary, the pleura being opened if already 
 wounded. If sufficient exposure is not obtained by forcible retraction 
 of the ribs, the costal cartilages abo\'e and below may be di^'ided 
 close to the sternum. The pericardium being opened and clots 
 evacuated, the slippery heart is grasped in the left hand, and the 
 wound sutured with a continuous chromic gut suture, hemorrhage 
 being intermittently controlled by pressure on the vense cavte at 
 their entrance into the right auricle (Rehn, 1907). Usually the 
 pericardium should be drained for twenty-four hours, and the pleura 
 also, if invaded, but through a separate incision. Simon has collected 
 
TlUiOMIiOSIS AND KM HOI. ISM 237 
 
 (up to 1912) 2n ()])(Tati()ns for ^nmsliot wounds, with 124 doaths 
 (51 por cent. nu)rtality); and 2()() operations for stab wounds, with 
 99 deaths (49 per cent.). 
 
 Foreign Bodies. Forei<2;n bodies in the heart have been recorded 
 in lis cases (Zcsas, 1910). Most have been jxjrtions of needles 
 or encysted bullets. The (Ha^nosis and localization arc aided by 
 radioj^raphy ; and extraction by cardiotomy is indicated if any 
 .syni])tonis are present. 
 
 Cardiolysis is an operation pr()i)()sed l)y Brauer (1902), and enii)l()yc(l 
 by Petersen, Simon, Morison, and others, consisting in excision of 
 portions of the fifth and sixth left ribs to allow more room for expan- 
 sion of a heart hypertrophied from aortic disease; much impro\-ement 
 in sym})toms is said to have resulted. Ilaberer (1910) employed 
 a similar operation for chronic adhesive j)ericarditis; while others 
 have gone further, opening the pericardium and freeing its adhesions. 
 Leriche and Cotte (1909) refer to IS operations of the latter type, 
 with marked improvement in all cases. 
 
 Pericardiotomy may be required for serous or purulent effusion 
 in the ])ericardium. A trocar may l)e introduced close to the stermim 
 in the fourth, fifth, or sixth left interspace, according to the physical 
 signs, or, which is preferred by Matas, at the left side of the base 
 of the ensiform. In most cases it is better to make a formal incision, 
 dividing the sixth and seventh left costal cartilages close to the 
 sternum. The latest series of 22 cases of pericardiotomy gives a 
 mortality of 82 per cent. (Elliott, 1909). 
 
 Massage of the heart, mentioned at p. 175 as useful in shock, 
 has been employed, according to Jurasz (1911); in 64 cases, with 13 
 permanent and 15 temporary recoveries. Two patients under m}^ 
 own care rallied only for a few hours. 
 
 DISEASES OF THE BLOOD VASCULAR SYSTEM. 
 
 Thrombosis and Embolism. — When blood coagulates within the 
 vessels during life, the process is called thrombosis, and the resulting 
 clot a thrombus. It is recognized clinically that there may be an 
 aseptic as well as a septic thrombosis, though the former becomes 
 rarer the more we learn of the subject. Infection may reach the 
 region of thrombosis through the blood-stream, or by contiguity 
 from neighboring parts; in the latter case it is customary to incrimi- 
 nate the perivascular lymphatics and the vasa vasorum as the avenue 
 of approach. Accepting, then, infection as the exciting cause of 
 thrombosis, we admit as predisposing causes anything which slows the 
 blood-stream , which produces changes in the vessel walls, or in the com- 
 position of the circulating blood. The most important of these three 
 doubtless is changes in the vessel walls; and these changes in most 
 instances are due to bacteria or their toxins. Aseptic injury seldom 
 is a cause of- thrombosis (p. 229). Moreover, changes in the vessel 
 walls, as in atheroma, phlebectasis, etc., also act by obstructing 
 
238 SURGERY OF THE BLOOD VASfTLAR SYSTEM 
 
 the blood-current; and- when the composition of the blood is altered 
 by disease {e. g., infections such as typhoid fever, appendicitis, sup- 
 purative inflammations; metabolic poisons, as in eclampsia, after 
 burns, etc.), or by injury (as after profuse hemorrhages), very slight 
 retardation may be sufficient to cause thrombosis. The thrombus 
 formed of circulating blood, within the vessels, is either of the white 
 or mixed variety: that is, it contains relatively few erythrocytes, 
 as these flow in the axial blood-stream furthest from the vessel walls 
 where thrombosis is inaugurated by depositon of blood-platelets, 
 destruction of leukocytes, and formation of fibrin ferment. The 
 thrombus thus formed may be a parietal thrombus only, not occlud- 
 ing the entire vascular lumen, or it may be a complete or obstructing 
 thrombus. In either case portions may be broken off by external 
 injury or simply by force of the circulation; and such an embolus, 
 being carried away in the blood-stream, may, when it is arrested 
 (embolism), produce a secondary thrombus, so named in contradistinc- 
 tion to the original primary thrombus. The thrombus, whether primary 
 or secondary, undergoes in time certain changes analogous to organiza- 
 tion, cicatrization, and contraction, as studied in Chapter I; by these 
 processes the vessel affected becomes converted into a solid fibrous 
 cord of connective tissue. Occasionally' small parietal thrombi are 
 absorbed: rarely obstructing thrombi become canalized by the gradual 
 development in them of capillaries which subsequently dilate and 
 re-establish permeability for the blood-stream; not seldom infective 
 thrombi disintegrate by suppuration, and then the emboli derived from 
 such a thrombus may cause metastatic abscesses (p. 73). Finally, 
 throml)i may become calcified, especially in veins, where they are 
 converted into phleboliths. 
 
 Phlebitis. — Phlebitis, or inflammation of a vein, is due in general 
 to the same factors mentioned above as causing thrombosis; and, 
 as may readily be understood from what was there said, thrombosis 
 is a much more frequent occurrence in veins than in arteries, ^'enous 
 blood normally clots more quickly than arterial; the normal venous 
 current is slow, is opposed by the force of gravity and by the valves 
 in the veins; the veins are superficial, not supported by the muscles, 
 and thus liable to trauma and to extension of infection from the 
 skin and its lesions; and their walls are thin, and liable to be varicose, 
 thus forming pouches where the blood eddies and stagnates. In 
 spite of all these factors which predispose to primary thrombosis, 
 it is not impossible for phlebitis to exist, at least for a time, without 
 thrombus formation. Thus in many cases of varicose veins (p. 242) 
 there is chronic phlebitis (phlebosclerosis), with marked thickening 
 of the venous walls, yet without thrombosis. Such cases probably 
 are due to the action of metabolic poisons, not to septic infection, 
 unless this is extremely attenuated. Surgeons thus distinguish 
 clinically between plastic and infective or .septic phlebitis, the latter 
 being accompanied in practically all cases by throml)osis, and running 
 a much more acute course. 
 
TlinOMBOSlS AM) KM HOLISM 
 
 289 
 
 Tlu" tliroinbus wliicli forms in a \('iM as a rule cxtciids rather raj)i(lly 
 ill the direction ot" the hlood-current, inxadinji; not int're(|ueiitly the 
 nearest brandies in the tiironihotic process; tlie clot extends also hut 
 to a less deforce on the distal side of the obstruction. Thus throm- 
 bosis be^imiiuf; in the lonff saphenous vein Ix'hind the internal malleo- 
 lus, or in the lower le^, may extend to the femoral; and from this 
 the iliac \eins and even the vena ca\a may become thrombosed. 
 Tiirombosis commencing in the appendicular veins may extend to 
 the portal vein and into the liver. Thrombosis commencing in the 
 facial or angular vein may extend to the cerel)ral sinuses; and throm- 
 bosis conunencing in the lateral sinus fre(|uently extends into the 
 internal jugular vein. 
 
 Symptoms. — These are the usual symj)ton)s of inflammation, more 
 or less localized to the known course of a \"ein. Pain fre(]uently 
 is the first symptom to attract 
 attention; examination soon after 
 discloses Jieat, a dusky redness in 
 the line of the veins ; and often the 
 thickened, tender, cord-like vein 
 can be palpated through the over- 
 lying tissues. Great gentleness 
 must be used in examination, for 
 fear of detaching an embolus. 
 Sometimes the position of the 
 valves can be recognized by the 
 presence of knobby protuberances, 
 ^"ery rarel>' suppuration occurs, 
 multiple abscesses forming along 
 the course of the vein. There is 
 moderate swell ing from the first, 
 and if thrombosis is complete, 
 and especially if a main trunk 
 is involved, there is a certain 
 amount of edema in the parts 
 beyond. In advanced cases there 
 is total disability of the affected 
 extremity. The disease lasts from 
 one to three or four weeks. Per- 
 manent occlusion of the affected 
 veins results in compensatory 
 dilatation of collaterals, whicli 
 may themselves be the cause of annoyance or (lisa})ility (Fig. 195). 
 
 Diagnosis. — Predisposing causes must be considered (infections, 
 injury), and the physical signs mu.st be accurately noted. By the 
 latter means phlebitis may l)e distinguished from (1) Lj/nijjhangelfis 
 (p. 2()<S), where the redness is more fiame colored, where the inffam- 
 mation seems more superficial, where it does not follow the known 
 course of a vein, where a thickened knobby cord cannot be palpated, 
 
 Fig. 19.5. — Eijisiastrio \'arioositips fol- 
 lowing typhoid thrombosis of iliac veins. 
 Episfopal Hospital. 
 
240 SURGERY OF THE BLOOD VASCULAR SYSTEM 
 
 and where lymphadenitis is a frequent accompaniment; from (2) 
 Periostcitis and Ofiieomyelitis, where the superficial veins are not 
 affected, where tenderness and pain are limited to the bone affected, 
 not extending past the nearest joint; where history of direct trauma 
 is frequent; and where tapping the suspected bone almost at any 
 part of its shaft is productive of pain at the seat of greatest disease; 
 and from (3) Neuralgia and Neuritis, where the symptoms are 
 localized to the known course of a ner^•e, and where no physical 
 signs of inflammation are present. 
 
 Post-operative Phlebitis has laparotomy as its most frequent cause, 
 and usually affects the veins of the left lower extremity. It not 
 infrequently occurs after apparently aseptic operations, and it runs 
 a comparatively mild course. Clark (1902) attributed it to injury 
 of the deep epigastric vein by the retractors used in abdominal 
 section. 
 
 Phlegma.sia Alba Dolens is a term used to describe inflammation 
 of the veins and lymphatics, usually of the left lower extremity, 
 and generally due to puerperal sepsis ("milk leg"). The usual signs 
 of phlebitis are present, but the disease is characterized especially by 
 the marked edema, rendering the skin tense and shiny, probably due 
 to coincident diffuse angeioleucitis ; and by the pallor of the affected 
 extremity. 
 
 Treatment. — Phlebitis is a serious disease, and requires efficient 
 treatment. Local rest, which usually implies confinement to bed, 
 and elevation of the limb, should be insisted on. Gentle support, 
 as by flannel bandages, aids elevation in preventing excessive edema. 
 Local applications have little appreciable effect, but the use of ice 
 bags in the early stages, and of heat later, usually is grateful to the 
 patient. Ichthyol or mercury and belladonna ointment may be 
 applied to the seat of greatest inflammation. The skin should be 
 kept clean, and well dried, by washing gently with alcohol once every 
 other day or so; but under no circumstances should massage be 
 attempted, and none but the very gentlest passive movement of the 
 extremity should be allowed. Absolute rest of the afl'ected part 
 should be maintained for at least one week after all symptoms hare 
 subsided. If the leg is affected there will be persistent edema for 
 many weeks or months after the patient gets about, and an elastic 
 stocking or firm bandaging will be necessary to promote ease in 
 locomotion. General treatment is the same as in any acute infection. 
 
 The treatment above described is sufficient in the immense majority 
 of cases of plastic phlebitis; but in some cases of septic phlebitis it is 
 proper to attempt to prevent the further spread of the thrombotic 
 process by excising a portion of the main venous trunk some distance 
 on the cardiac side of the furthest limits of inflammation. Thus for 
 thrombosis extending up the long saphenous vein, this trunk may be 
 doubly ligated and a section excised (Fig. 196), or the vein simply 
 divided, at the saphenous opening. In thrombosis of the lateral 
 sinus, following otitis media, it is the rule to divide the internal 
 
THROMBOSIS AM) EMIiOLlS.U 
 
 241 
 
 juj;iilar, wIutc licaltliy, between two ligatures; and some surgeons 
 advise ligating all hranohes and excising as much as possible of the 
 tlironil)()S(>d venous channels. In septic thrombosis of the oxarian 
 veins, following ])uer])eral metritis, many surgeons ha\e attempted to 
 prevent propagation of the thrombus by ligation above the limit of 
 disease (('hai)ter XXIX). The operation of phlebotomy, with extrac- 
 tion of the dot and suture of the vein is 
 not so ])romising as arteriotomy for 
 arterial eml)olism (p. 242), as the 
 intima of the thrombosed vein is so 
 diseased as almost necessarily to ensure 
 recurrence of thrombosis; nor is the 
 operation so desirable, since gangrene 
 is less to be feared than from arterial 
 occlusion. Wolff (1908) showed that 
 in the lower extremity operative occlu- 
 sion of the main arteries (137 cases) 
 caused gangrene in 20 per cent, of 
 cases; while occlusion of the femoral 
 vein alone (31) cases) resulted in gan- 
 grene in less than G per cent. In the 
 upper extremity arterial occlusion (153 
 cases) caused gangrene in about 8 per 
 cent.; only one case of ligation of the 
 (axillary) vein was recorded, which did 
 not result in gangrene. 
 
 Pulmonary Embolism. — Pulmonary 
 embolism, sometimes an alarming con- 
 sequence of venous thrombosis, and 
 often occurring at the onset of post- 
 operative convalescence, has been considered at p. 178. Other forms 
 of venous embolism, affecting the viscera (especially the liver), are of 
 comparatively little surgical interest, except when occurring in pyemia. 
 
 Arteritis. — Arteritis requiring surgical treatment is a much rarer 
 condition than phlebitis. In chronic arteriosclerosis, with threatening 
 or even developed gangrene (so-called senile or presenile gangrene), 
 reversal of the circulation, as suggested by Carrel and Guthrie, has 
 been attempted, by anastomosing the femoral artery and vein; the 
 theor\' being that the veins, their valves being incompetent, ofTer 
 less peripheral resistance to the outflowing blood-current than the 
 sclerotic arteries. Though the operation appears to have been under- 
 taken in about (53 cases (Zesas, 1912), there was cure or improvement 
 in only 8 instances; whether such results justify the hazard of the 
 primary operation must be determined for each case individually. 
 (See Senile Gangrene, p. 61.) 
 
 Arterial Thrombosis. — Arterial thrombosis occurs as a complication 
 of wounds, compound fractures, cellulitis, etc.; but unless affecting 
 the main artery of a limb, which is rare, its symptoms usually are 
 16 ' 
 
 Fig. V.HJ. — Portion of thronibosod 
 internal saphenous vein, excised at 
 its juncture with the femoral. 
 Episcopal Hospital. 
 
242 SURGERY OF THE BLOOD VASCULAR SYSTEM 
 
 overshadowed by those of the causative condition. When the main 
 artery of a limb is affected, the symptoms differ only in the less sudden 
 onset from those of arterial embolism, presently to be described. 
 F. T. Stewart (1908) refers to 35 cases of traumatic arterial thrombosis, 
 31 of which terminated in gangrene. The treatment is the same as 
 for embolism. 
 
 Arterial Embolism. — Arterial embolism, when affecting the main 
 artery of a limb, is a condition of great gravity. The clot usually 
 is derived from one of the cardiac valves; it is detached from no 
 apparent exciting cause, is carried away in the blood-stream, and if 
 lodging so as to ])lug an artery of considerable size, presents charac- 
 teristic and well marked symptoms. The patient suffers a sudden, 
 acute, stinging pain below the site of embolism, in the distribution 
 of the affected artery; the limb below becomes tingling, numb, or 
 for a time the seat of burning pain; pulsation is absent below the 
 site of embolism; and the limb gradually grows cold, bluish, livid, 
 and the signs of oncoming gangrene appear (p. 60). Fig. 20 (p. 62) 
 shows gangrene due to lodgement three weeks previously of an embolus 
 in the popliteal artery, in a patient who three months before had 
 embolism of a cerebral artery. 
 
 Treatment. — When the embolus lodges in an accessible situation, 
 and in one where sudden complete arterial occlusion habitually 
 results in gangrene (especially the brachial at the elbow, the femoral 
 and popliteal arteries), the surgeon should lose no time in resorting 
 to arteriotomy and extraction of the clot (F. T. Stewart, 1908). 
 This is a more promising procedure for embolism with secondary' 
 thrombosis, than for primary thrombosis, since the healthier con- 
 dition of the arterial coats in the former condition makes recurrence 
 of thrombosis less likely. According to Le Conte and Stewart (1910) 
 arteriotomy for thrombosis or embolism has been done in 7 cases; 
 at least 3 of the patients died, and in none was gangrene prevented. 
 Since the publication of these statistics one successful case of arteri- 
 otomy for femoral embolism (aseptic) has been reported by Mosny 
 and bumont (1911). 
 
 Varix, Phlebectasis, or Varicose Veins, describes a condition in 
 which the veins become elongated, dilated, tortuous, and pouched. Any 
 veins may be affected, even those of bone; but superficial veins, 
 especially the ^'eins of the spermatic cord and the saphenous ^'eins 
 of the lower extremities, are most noticeably diseased (Fig. 197). 
 The chief cause is gravitation, aided by obstruction to the normal 
 venous current. Occupation (barbers, waiters, motormen, or others 
 who stand for hours at a time), tumors, pregnancy, thrombosis (Fig. 
 195), or other factors producing obstruction, are all predisposing 
 causes. Usually no one well defined cause can be found. The valves 
 become incompetent, the blood stagnates, hypertrophy and sclerosis 
 of the vessel walls occur, phleboliths may develop, and thrombosis 
 may finally cause obliteration of the diseased veins. The symptoms 
 of pain, fulness, weight, etc., are frequently disabling; in the lower 
 
VARICOSE VEINS 
 
 243 
 
 Fig. 197. — -Varicose internal 
 saphenous vein, aged sixty-three 
 years ; duration over forty years. 
 
 extremities the perivascular tissues become thickened, liard edema 
 develops, the nutrition of the skin suffers; trifling trauma produces 
 an abrasion which fails to heal, and varicose ulcer results (p. 57). 
 Profuse hemorrhage may occur from 
 spontaneous rupture of a varix. Rup- 
 ture of a deep varicose vein is attended 
 by sudden stinging pain ("coup dc 
 fouet") and subsequent appearance of 
 ecchymosis. • Treatment may be pallia- 
 tive or radical. The former includes 
 api)lication of elastic bandages or 
 stockings, after emptying the veins 
 and reducing edema by elevation of 
 the limb; the use of stimulating lini- 
 ments, etc.; and attention to hygiene. 
 Such treatment always should be tried 
 first, and usually is efficient when the 
 cause of the obstruction is temporary 
 (pregnancy), or removable (tumor, 
 etc.). In other cases, or when pallia- 
 tive measures fail to relieve symptoms, 
 operation is indicated. If the super- 
 ficial veins are varicose as a result of thrombotic obstruction of the 
 deep veins, no operation should be attempted unless elastic support 
 with temporary obliteration of the varicosities produces relief and 
 demonstrates the efficiency of the collateral circulation. Very occa- 
 sionally varicosities due to this cause disappear spontaneously 
 after a few vears, owing to the development of collateral circulation 
 (Skillern, 1913). 
 
 Operative Treatment. — Operative treatment consists in obliteration 
 of the varicose channels at one or several points. Schede's operation 
 (1877) is done by making a circular incision below the knee down to 
 the deep fascia, thus dividing all the superficial veins; both ends of 
 each divided vessel are then ligated, and the skin sutured. This 
 operation also divides the superficial lymphatics and sensory nerves; 
 sometimes is followed by edema, paresthesias, neuralgias, or trophic 
 disturbances in the skin below; and, according to Matas, is followed 
 by permanent cure in only one-third of the cases. Spiral division of 
 the skin enables the surgeon to obliterate all the venous channels 
 without severing all the- lymphatics, thus rendering edema less 
 likely; but section of the nerves can scarcely be avoided. Tre?i- 
 delenburg's operation (1890) consists in division of the main varicose 
 trunk (usually the long saphenous above the knee) between two 
 ligatures, the object being to break the column of blood, thus relieving 
 pressure symptoms. It is suitable for those cases where only the 
 main trunk, not its collaterals, is varicose; and is not suitable even 
 for those cases if the saphenous vein is the seat of chronic phlebitis. 
 According to Matas, 79 per cent, of patients treated by Trendelen- 
 
244 SURGERY OF THE BLOOD VASCULAR SYSTEM 
 
 burg's operation have been cured or' greatly improved. Multijde 
 Phlebcctomi/, associated with the names of Madelung (1884) and 
 Schwartz (1888), is, I beheve, the best operation in the vast majority 
 of cases. Sections of the diseased veins, three or four inches long, 
 ^are removed at the saphenous opening and in other parts of the thigh 
 and leg, wherever the main trunks or their branches are most dilated ; 
 the intervening portions become thrombosed, contract, and produce 
 no further symptoms; and the greater portion of the diseased tissue 
 is completely removed from the body, which is not accomplished by 
 either Schede's or Trendelenburg's operation. If the surgeon wishes, 
 he can remove the entire saphenous vein through one long incision; 
 or by passing a curette over the ligated end of the main trunk, as 
 practised by C. H. Mayo (1906), and ripping off its branches by 
 subcutaneous tunnelling with this instrument, the entire vein may 
 be removed through three or four small incisions. These methods, 
 though more spectacular than multiple phlebectomy, which is a 
 tedious procedure, are less sure, since the diseased collaterals are 
 left behind. In many cases, moreover, the veins are calcareous, 
 and so densely adherent to the perivascular tissues and even to the 
 skin, that only a formal dissection can free them. I have always 
 employed multiple phlebectomy, except in cases due to thrombosis of 
 the deep veins; in these I have adopted a spiral incision for Schede's 
 operation, thus avoiding excision of the only veins the patient 
 possessed. Operations for varicose veins are not entirely devoid of 
 danger: in large series of operations death from pulmonary embolism 
 has occurred in 1 or 2 per cent, of cases; the skin frequently is difficult 
 to sterilize, and in spite of care infection of the incisions may occur; 
 occasionally phlebitis is a sequel. 
 
 Hemangeiomas ; Telangiectases. — Under these terms are included 
 various affections of the vascular system, whose proper classification 
 has not been determined by pathologists. In the vast majority of 
 cases they are cojigenital, or at least are noticed first in early infancy; 
 the lesions usually enlarge more rapidly than the part in which they 
 are situated, and from being insignificant specks at birth may become 
 growths of alarming size in childhood or early adult life. Sometimes 
 they assume the character of tumors, as descril)ed in Chapter IV, 
 very occasionally seeming to possess malignant characteristics (in- 
 filtration, recurrence). 
 
 Nevus Vasculosus. — This may affect either capillaries or venules, 
 its color (bluish, purplish, or red) depending upon the proportion of 
 venous blood present. 
 
 Capillary Nevi (Plate II, Fig. 1). — Capillary nevi occur in the skin, 
 rarely in mucous membranes; they do not involve the subcutaneous 
 tissues; they are red, or reddish blue ("mother's mark," "birth-mark," 
 "port-wine stain"); they may be elevated above the surface of the 
 surrounding skin, or may lie perfectly flat beneath a seemingly normal 
 epiderm. They vary greatly in size. Elevation of the affected part 
 does not cause them to shrink or become pale; nor does pressure 
 
HEMANGEIOMA AND NEVUS 
 
 245 
 
 blaiuli tlii'iii, unless very small, and then only momentarily. Tsually 
 they are nuilti])le, are most frecjuent on the face and neck (])erhaps 
 branchi()«;('nic) ; tend to ji^row lar<i;er; and may ulcerate and cause 
 alarming liemorrhage. Sometimes they blend into caccrnous angeio- 
 mas, described below. The pigmented mole may be considered a 
 \ariety of capillary nevus: fre- 
 ((uently it is hairy (netu.'i /j/Zoa'?/*, 
 Fig. MIS); usually remains of in- 
 significant size; but occasionally 
 about puberty, or in adult life, 
 from trifling of no apparent cause, 
 begins to enlarge, assumes tumor- 
 like characteristics, and may de- 
 velop into or be inexplical)ly asso- 
 ciatetl with melanotic sarcoma (p. 
 129). 
 
 Treatment. — The treatment of 
 capillary nevi should be under- 
 taken within the first few months 
 of life. The application of carbon 
 dioxide snow (Pusey, 1907), for a 
 half minute or so, every three or 
 four days, probably is the most 
 satisfactory treatment for the port- 
 wine stains or other nevi not raised above the surface of the sur- 
 rounding skin. This "cold caustic," as it has been called, produces 
 sloughing of the diseased skin, resulting in an ulcer which heals with 
 the minimal amount of scarring. The earlier the nevus is cured, the 
 more inconspicuous will the scar be. Fuming nitric acid is more 
 effectual for raised capillary nevi than for port-wine stains. Elec- 
 trolysis may also be em- 
 
 Fk;. lOS.- -.\c\us pilnsiis I luiiry mole). 
 Age nineteen years, growing slowly 
 since birth. Episcopal Hospital. 
 
 ployed. Moles are best 
 treated by excision. 
 
 Venous Nevi. — ^'enous 
 nevi may occur in the skin 
 or subcutaneously, in the 
 latter case usually being de- 
 scribed as cavernous angeio- 
 mas, their structure resem- 
 bling the cavernous tissues 
 of the penis. They form 
 prominent lobulated tumors, 
 easily compressible, some- 
 times becoming tense when the child cries or strains, emptying more 
 or less completely when the affected part is elevated and pressure is 
 applied, and rapidly refilling when the part is dependent (Figs. 199, 
 200). In the subcutaneous variety discoloration of the skin may not be 
 present. The growths may be circumscribed or diffuse ; the former some- 
 
 FiG. 199. — Cavernous angeioma of palm, hand 
 dependent. From a patient under Dr. Frazier's 
 care in the Episcopal Hospital. 
 
246 
 
 SURGERY OF THE BLOOD VASCULAR SYSTEM 
 
 times is mistaken for a cold al)scess; while the diffuse su})Cutaneous 
 cavernous angeioma may involve an entire extremit}^ and neighl)oring 
 
 portions of the trunk, the en- 
 tire limb being deformed, 
 flabby, pudgy, and sponge-like 
 to the touch (pseudo-elephan- 
 tiasis); the muscles may be 
 wasted, and the bones atro- 
 phic (Plate III) . Muscle tissue 
 itself may be invaded by the 
 angeiomatous growth. Similar 
 angeiomas occasionally are 
 found in the viscera, notably 
 the liver. Subcutaneous caver- 
 nous angeiomas usually are 
 associated with lipomatous 
 growths {newid lipoma). They seldom cause hemorrhage but may 
 undergo thrombosis; and formation of phleboliths is not uncommon. 
 Treatment. — Treatment consists in excision whenever this is 
 practicable; and in circumscribed angeiomas it usually is not very 
 difficult. If excision be refused by the parents, the surgeon may 
 strangulate the tumor by ligating it in sections, leaving the protruding 
 masses to be separated as sloughs. A round nevus may be strangulated 
 by a double or quadruple ligature (Fig. 201 ), while an elongated growth 
 
 Fig. 200. — Cavernous angeioma of palm, hand 
 elevated. Episcopal Hospital. 
 
 Fig. 201. — Strangulation of nevus by the quadruple ligature: A, the ligature being 
 introduced; B, the loops have been cut and the ends of the ligatures tied. 
 
 may be attacked by Erichsen's method (Fig. 202). In cases where 
 an elastic tourniquet or other means of controlling the circulation 
 can be applied above the seat of operation, Wyeth's method (1903) 
 may be adopted: this consists in the repeated injection of boiling 
 water (1 to 2 c.c), at intervals of several days; if the water is actually 
 boiling, thrombosis of the blood in the angeioma will be immediate 
 and the clot so firm that theoretically no fear of embolism need 
 occur; but though no such result has been reported, so far as I am 
 
< 
 
 Oh 
 
ANEl'in-S.\f 
 
 IW 
 
 aware, the siir<;('()ii should I)r rxtrciiicly cautious in ('ini)loyin^ this 
 uu'thoil ahout the lace, where eerehral enihohsin iui<i;ht occur, or at 
 the root ot" the neck or iu the axilhi, where ])uhnoii!ir\ enihohsm 
 nii^ht he caused. I )iiruse suhcutauetMis caxcrnoiis anji'eioiuiis usu.illy 
 can he tn^ited only hy palliation. 
 
 Fig. 202. — Lif^atioii of a nevus hy Erichsen's method: one-half the thread i.s dyed 
 l)Uick; after the Usature has been inserted in serpentine manner {A), the black loops 
 arc cut on one side and the white loops on the other side o( the nevus, and the black 
 ends are ticnl to the black, the white to the white. 
 
 Arterial Varix. — Arterial varix, know^n also by the name of Cirsoid 
 Aneurysm (Fig. 203), and, when capillaries are involved, by the terms 
 Racemose Aneurysm and Aneurysm by Anastomosis, is an affection of 
 the arterial system somewhat analogous to varicose veins, but present- 
 ing in many cases neoplastic characteristics by which it is allied to 
 angeiomas. The arterial distribution affected (most frequently on the 
 scalp) becomes dilated, elongated, tortuous, and imuched, forming a vari- 
 cose pulsating timior often of considerable size. It occurs usually in 
 early adult life, from no well defined cause, though history of trauma 
 may be obtainable, and cases have developed from congenital nevi. The 
 tumor presents a characteristic varicose appearance, is compressible, 
 and may be reduced in size by pressure on the main afferent arterial 
 trunks; when this pressure is removed, the tumor again increases 
 in size, by expansile pulsation, perhaps several cardiac impulses 
 being required before it regains full size. Palpation and auscultation 
 detect a systolic thrill. 
 
 Treatment.^Treatment is sought by the patient for relief from the 
 constant murmur or whirr within the tumor, as well as on account 
 of the deformity. Excision should be done when practicable; some- 
 times it becomes possible only after preliminary circumferential 
 ligation of the main arterial channels entering the tumor (Fig. 203). 
 In rare cases such ligation alone is sufficient to cause disappearance 
 of the tumor. 
 
 Aneurysm. — An aneurysm is a hollow sac, filled with normal or 
 altered blood, in communication with the lumen of an artery, and 
 developed wholly or in part by progressive dilatation of the arterial 
 walls. A traumatic aneurysm (p. 233) properly is not an aneurysm 
 
248 
 
 SURGERY OF THE BLOOD VASCULAR SYSTEM 
 
 at all, but a pulsating hematoma, since the sac is formed not of arterial 
 wall, but by condensation of surrounding tissues. Arterial aneurysms 
 are classified as true and false; formerly the term "true" was applied 
 only to those aneurysms composed of all the arterial coats; but as 
 this condition was found to exist only in an extremely limited number 
 of cases of very minute (miliary) aneurysms, it has now been trans- 
 ferred to all aneurysms developed wholly or in part by progressive 
 dilatation of the arterial walls; while the term "false aneurysm" is 
 now applied only to ' pulsating hematomas, etc. When a true 
 aneurysm ruptures subcutaneously it is better to call it a "ruptured 
 aneurysm," than a diffused or consecutive aneurysm (Fig. 204). 
 
 Fig. 20.3. — Cirsoid aneurysm, arterial vanx, 
 or aneurysm by anastomosis of right ear, treated 
 by a series of operations by the late Prof. 
 Ashhurst: 1. Ligation of temporal and common 
 carotid arteries. 2. Ligation of growth by Erich- 
 sen's method (Fig. 202). .3. Amputation of ear, 
 excision of tumor, and ligation of cut vessels 
 separately. University Hospital. 
 
 Fici. 204. — Rui)tured aneurysm 
 of left femoral artery; ligation in 
 Scarpa's triangle thirteen years ago 
 for popliteal aneurysm. Rupture 
 two weeks ago. Episcopal Hospital. 
 
 Aneurysm develops by the gradual dilatation of a portion of the 
 arterial wall previously diseased. At this earliest stage the term 
 arteriectasis is applicable. As the dilatation proceeds, the middle 
 tunic gives way, and the aneurysmal wall is formed only of the 
 adventitia with such clots as may be deposited from the swirling 
 blood within the sac upon the surface of the intima. The walls of an 
 aneurysmal sac in contact with circulating blood always are lined 
 by endothelial cells, which are proliferated with great readiness either 
 by extension from the intima of the parent artery, or possibly 
 through the medium of angeioblasts of the vasa vasorum (Matas, 
 1910). This endothelial lining may itself become atheromatous and 
 calcareous. 
 
ANEURYS.U 
 
 249 
 
 Aneurysms are fiirtlier classified as to their /o/v/i, into (1) Tubular 
 or Fu^siforiii (Fiji- -^)'>); (-) Saccular (Fig. -0(»); and (3) Disscctinxj 
 Aneury.s)ii.s. Tubular or fusiform aneurysms are those which involve 
 the entire circunifereiice of an artery, and are rare even in the larger 
 
 Fig. 205. — Fusiform anour\!5ni. 
 
 Fig. 200. — Saccular aneurysm, with 
 small mouth. 
 
 internal vessels. Dissecting aneurysms are those in which the blood 
 makes a channel for itself between the coats of the arterial wall for a 
 variable distance, and again enters the arterial lumen; they are seen 
 almost exclusively in the tho- 
 racic or abdominal aorta. The 
 saccular aneurysm, in which the 
 dilatation involves a portion 
 only of the arterial circumfer- 
 ence, communicates with the 
 vessel by a comparatively small 
 orifice called the mouth of the 
 sac; by progressive growth of a 
 saccular aneurysm its mouth 
 may become so lengthened as 
 to cause the aneurysm to re- 
 semble at first glance one of 
 tubular or fusiform variety, 
 especially on laying open the 
 sac, when it will appear that 
 there are two mouths present 
 (Fig. 207, B). Though aneu- 
 rysms usually are single, they 
 
 may be multiple; and after cure by obliteration of one sac others may 
 develop (Fig. 204). 
 
 The sac of an aneurysm when first formed contains fluid blood; 
 the eddying and partial stagnation to which this is constantly sub- 
 
 FiG. 207. — Saccular aneurj-sm with large 
 mouth; when opened it appears as if there 
 were two orifices. 
 
250 
 
 SURGERY OF THE BLOOD VASCULAR SYSTEM 
 
 jected leads in time to the deposition of fibrinous clots on the interior 
 of the sac wall. These are deposited in successi\e layers, constituting 
 the laminated clot. This rarely l)ecomes firmly adherent in all spots 
 to the sac wall, but is dissected loose by the eddying currents, thus 
 preventing its organization. Should such firm adhesion and organiza- 
 tion occur, and should concentric laminations be formed continuously, 
 spontaneous cure of the aneurysm eventually might ensue by oblit- 
 eration of its sac; but this is extremely rare. 
 
 Causes.— The chief underlying cause of aneurysm is precedent 
 disease of the vascular system; aneurysm is but a symptom of this 
 disease; and in the immense majority of cases the vascular degenera- 
 tion is a sequel of syphilis, ^ though chronic alcoholism, even without 
 syphilitic affection, is saifl sometimes to be a cause. The immediately 
 apparent cause, in most cases, is some sudden strain, exertion, or 
 
 accident, which causes rui> 
 ture of the diseased media at 
 its most susceptible point; 
 the vis a tergo of the blood- 
 stream then causes progres- 
 sive dilatation of the artery 
 until a well defined aneurysm 
 exists. Constantly recurring 
 slight trauma is recognized as 
 a predisposing cause in that it 
 causes localization of arterial 
 lesions where aneurysms later 
 develop. Thus is explained 
 the preponderance of aneu- 
 rysm in the aortic arch and at 
 the root of the neck, where 
 not only is the cardiac im- 
 pulse strongest, but where 
 the arteries lie against bone 
 (vertebrse, first rib, clavicle) and where each pulsation tends to bruise 
 the arteries against this unyielding structure; the latter explanation 
 is adduced by Barwell (18S2) to account for the frequency of popliteal 
 (Fig. 208) as compared with brachial aneurysm. 
 
 Localization. — In general terms, the aorta is affected in 42 per 
 cent., the popliteal artery in 24 per cent., the femoral in 12 per cent., 
 and the carotid, subclavian, axillary, and innominate in about 3 
 per cent, each — leaving the smaller arteries of the extremities to form 
 about 10 per cent, of cases (Crisp, 1847). Popliteal aneurysm forms 
 from 55 to 60 per cent, of those occurring in the limbs (Matas, 1910). 
 Age. — Aneurysm occurs mostly in patients in active adult life; 
 about two-thirds of cases are seen between the ages of thirty and 
 fifty years, after arterial lesions have had a chance to develop, 
 
 Fig. 208.^Poijliteal aueurysni, right leg. Dr. 
 Harte's case. Pennsylvania Hospital. 
 
 1 This was streniiouslv denied bv Barwell (1882). 
 
SYMPTOMS OF AXE!'RyS.\f 251 
 
 and wliile sudden strains arc still IVccjiiciit. .SV'.r; It is seen in men 
 al)()ut six or seven times as fre(iuently as in women, owing to the 
 greater liability of the male sex to atheroma, and to their more labori- 
 ous life. Occupations attended b.y violent exertion (porters, teamsters, 
 soldiers, sailors) are regarded as })redisi)osing to the de\eloi)ment 
 of aneurysm, as are diseases of the heart and kidneys, chronic gout, 
 rheiiniatisni, etc., causing arterial hypertension and calcification. 
 
 Symptoms. — These usually are of slow develoi)ment, though occa- 
 sionally the ])atient is aware that "something has given way," expe- 
 riences a sudden stinging pain, as the "coup de fouet" in rupture 
 of deep varicose veins (p. 243), and on examination at once finds a 
 pulsating tumor has formed. The symptoms of aneurysm may be 
 considered as those peculiar to the aneurysm itself, and those due to 
 its pressure on surroundi}ig parts. There is present a rounded or 
 oval tumor, either apparent to the eye or appreciable to the touch; 
 it is situated along the course of an artery; it is movable laterally 
 but not longitudinally on the artery; and it is somewhat compressible 
 and elastic (depending on the amount of laminated clot). An aneurysm 
 becomes more or less flaccid by pressure on the artery above, and 
 harder and more tense by pressure on the artery below^ the tumor. 
 It is covered by healthy, non-adherent skin, unless in the last stages 
 when rupture is about to occur. The affected part is more or less 
 disabled, with muscular weakness, paresthesia, numbness, or edema 
 (pressure effects) : pressure on nerves causes neuralgic pain or paralysis 
 (of pupil, of vocal cord, etc.); on neighboring veins causes varicosities 
 and edema; on arteries (perhaps the parent trunk) causes gangrene; 
 on bones causes erosion, with intense boring pain; on neighboring 
 viscera (trachea, esophagus, bile ducts, etc.), may cause serious 
 disturbance in their functions. Aneurysms pulsate, synchronously 
 with the heart: they are not merely lifted by the pulsation of the 
 underlying artery, but as the blood enters the sac and swirls around 
 in its interior the sac walls dilate, causing an extremely character- 
 istic pulsation wdiich is both eccentric and expansile. The degree of 
 aneurysmal pulsation depends on the size of the sac and of its mouth, 
 and on the thickness of its walls; a small aneurysm with much thick- 
 ened walls and a small mouth connecting with the artery will pulsate 
 much less than one w^hich is large, thin walled, and possessed of a large 
 mouth. Pulsation becomes more pronounced when the part is depend- 
 ent and Avhen pressure is made on the artery below the sac, and may 
 almost disappear when the limb is elevated and the artery occluded 
 above the sac. When pulsation has been made to cease b}' the latter 
 method, application of the hands over the sac will enable the surgeon 
 to detect the entering blood when pressure is removed, and will 
 make him appreciate the facts that the sac does not always become 
 fully distended with the first impulse from the heart, and that the 
 pulsation is eccentric and expansile, driving the hands not only 
 further away from the underlying artery, but also further apart 
 from each other. Pulsation in the artery below the aneurysm may be 
 
252 SURGERY OF THE BLOOD VASCULAR SYSTEM 
 
 much diminished, as compared with corresponding pulsation on the 
 other side of the body; this phenomenon is due to pressure on the 
 artery by the overlying aneurysm; while the fact that the pulse below 
 the aneurysm may be delayed is explicable on mechanical grounds, 
 the aneurysm acting as the air-chamber of an hydraulic ram. INIore- 
 over, the arterial pressure distal to the aneurysm is less than in the 
 corresponding healthy artery. Bruit, which is the peculiar whirring 
 or rasping noise made by blood entering the sac, is present with very 
 few exceptions (old thick-walled aneurysms almost full of clot); it 
 occurs during cardiac systole, is therefore intermittent, and is loudest 
 in aneurysms with large sac mouths; it may be made to cease by 
 obliteration of the artery above the aneurysm, unless large collaterals 
 empty into the sac; and in aneurysms of the extremities sometimes 
 becomes louder when the limb is elevated. It may be transmitted 
 centrifugally along the diseased artery. Thrill is to the hand what 
 bruit is to the ear; but is much less marked than in arterio-venous 
 aneurysms. 
 
 Course and Termination. — Aneurysm is an incurable disease, and 
 if left to itself first disables and then kills the patient within com- 
 paratively few years. Apparent cure is only temporary, as other 
 aneurysms ma}' develop or the first recur. By proper treatment, 
 howe^Tr, symptoms may be relieved, individual aneurysms may be 
 temporarily cured, and the life of the patient may be prolonged 
 indefinitely (perhaps fifteen to twenty years) in comfort and reasonable 
 usefulness (Fig. 204). Death finally comes slowly (from exhaustion, 
 inanition, gangrene, etc.), rapidly (from pressure on trachea or larynx, 
 on phrenic or pneumogastric nerve, from rupture and hemorrhage, 
 etc.), or suddenly from syncope even without rupture. 
 
 Diagnosis. — This is made by attention to the history and physical 
 signs. Arterio-venous aneurysms usually follow penetrating wounds; 
 other signs of vascular disease may be wanting; bruit is continuous 
 (not intermittent except sometimes when the limb is elevated — 
 Nelaton), is transmitted both centrifugally and centripetally; thrill 
 is marked; and compression on the afferent and efferent arterial 
 trunk does not cause such characteristic changes in the sac. Other 
 vascular pulsating tumors are less well defined in outline, do not 
 present eccentric pulsation, have little or no bruit, and are not neces- 
 sarily placed in the course of a large artery. Other tumors may pulsate 
 because they overlie an artery, but the pulsation is neither expansile 
 nor eccentric, there is neither bruit nor thrill, and obliteration of the 
 aft'erent or efterent arterial trunk, while it may cause cessation of 
 pulsation, yet produces no other change in the tumor. Xon-pulsating 
 tumors may be mistaken for an aneurysm with contents clotted; such 
 grow'ths may be movable longitudinally as well as laterally, and 
 present a different clinical history. iVn aneurysm which has become 
 diffused or inflamed may be mistaken for an abscess (p. 49), but 
 attention to the history, and a careful physical examination will 
 almost surely prevent any confusion. 
 
TREAT MEM' OF ANEL'in'^M 253 
 
 Treatment. -This may be operative or non-operative. Under the 
 latter licadinu are inchuled hyfjienic and dietic measures, such as 
 alone are aj)pli(al)le to certain forms of internal aneurysm. All other 
 aneurysms should be operated upon, and nothing is gained by delay. 
 The end sought by operation is to prevent blood from entering the 
 sac, thus allowing its obliteration. This may be attempted in various 
 ways. The methods still in most general use endeavor to secure 
 coagulation of the blood within the sac; these may be regarded as 
 palliative operations. ]\Iost of them act by retarding the current of 
 blood passing through the parent artery; others act directly on the 
 contents of the sac itself. They inchide ])ressure on the afferent 
 artery; compression of the sac itself (as by flexing the knee for pop- 
 liteal, or the hip for inguinal aneurysm), ligation of the afferent artery, 
 or of the efferent artery or one of its branches; injection of coagulating 
 fluids; insertion of needles with irritation of the intima to favor throm- 
 bosis; and introduction of metallic wire with electrolysis. Manipula- 
 tion of the sac (Fergusson, 1857), in an effort to detach a clot which 
 shall plug the efferent artery, should be mentioned only to be con- 
 flemned. Radical operations comprise extirpation of the sac, with 
 suture or ligation of the orifice or orifices into the parent artery; 
 and Endo-aneurysmorrhaphy, which is the best method whenever 
 applicable. 
 
 Pressure. — The patient should be confined to bed, and kept on 
 a low diet with very little fluid; this slows the circulation and favors 
 thrombosis (Tufnell, 1864). The pressure may be either instrumental 
 (by various forms of tourniquets), or digital (Knight, 1844), which 
 is preferable. The afferent artery is compressed until the sac ceases 
 to pulsate. Relays of assistants are required, each one keeping 
 up pressure for from three to five minutes, being then relie\'ed by 
 another who compresses the artery above or below the first point 
 of compression before this is released by the fingers of the former 
 assistant. In this way the circulation of blood in the sac is much 
 diminished, favoring the formation of a laminated coagulum. Treat- 
 ment is to be kept up for from two to four days, in sittings of about 
 four hours once daily. After thirty-six hours hope of cure is much less, 
 and continuation of pressure dangerous (sloughing, etc.). The method 
 is most easily applicable to the femoral artery, for aneurysm of the 
 popliteal. It should be employed only when endo-aneurysmorrhaphy 
 or ligation are contraindicated, as in the very old and feeble, in those 
 with serious visceral disease, etc., in whom the dangers of a cutting 
 operation are excessive. The method is successful in perhaps half 
 the cases treated. G. Fischer (1869), found that among 188 cases 
 of aneurysm treated b}' digital compression, cure resulted in 121 
 (over 64 per cent.), and 38 of these patients were cured in less than 
 three days; of 90 cases of popliteal aneurysm, 72, or 79 per cent., 
 were cured by digital compression. 
 
 LiGATiox. — This may be done on the proximal side of the aneurysm, 
 or the distal, or on both sides. 
 
254 
 
 SURGERY OF THE BLOOD VASCULAR SYSTEM 
 
 Froximal Ligation. — The method of Hunter (1785) consists in 
 applying a ligature some distance above the aneurysm, allowing small 
 branches to convey blood from above the ligature through collateral 
 circulation, into the sac of the aneurysm (Fig. 209). The advantages 
 claimed for the Hunterian method are: (1) accessibility of the artery; 
 (2) healthier condition of the arterial walls; (3) gradual obliteration 
 of the sac by formation of laminated clot. But modern aseptic oper- 
 ating renders the artery easily accessible at any site, and even if 
 the arterial wall be diseased close to the sac (which is not certain), 
 application of a ligature will strengthen it, and healing will occur 
 normally. Objections to Hunter's operations are: (1) the existence 
 of collateral circulation through the sac really is unfavorable to its 
 
 Fig. 209. — Hunter's method of liga- 
 tion for aneurysm: collateral circula- 
 tion from above the ligature into the 
 sac. 
 
 Fig. 210. — Anel's method of ligation for 
 aneurj-sm: circulation through the sac com- 
 pletelj' arrested. 
 
 complete obliteration; (2) interposition of two obstacles to the circu- 
 lation (ligature and aneurysm) renders gangrene more likely, as does 
 the exclusion from the circulation of collaterals arising between the 
 ligature and the sac; (3) if the collateral circulation is successfully 
 established through the main trunk, recurrence of the aneurysm is 
 likely. The method of Anel (1710), revived in 1856 by Broca, con- 
 sists in the application of a ligature close to the sac (Fig. 210); until 
 recent years it was considered inferior to Hunter's operation, but 
 aseptic technique has shown it to be quite as safe and but slightly 
 more difficult; and its manifest advantages are that the circulation 
 through the sac is completely suppressed and yet no additional 
 obstacle is erected to the circulation, only one set of anastomosing 
 vessels being required, instead of two, as in Hunter's operation. 
 
THE ATM EXT OF ANEURYSM 
 
 255 
 
 jNIatas, Di'lhct, WoIht, Kolilor, LeCoiito and Stewart all jjrefer Aiiel's 
 metluxl to that (jt" Hunter. 
 
 Distal lUjatioii also depends for its curative effect on retardation 
 of the circulation within the artery, with consequent thrombosis in 
 the aneurysmal sac. Bnmlors wet hod (1798) consists in ligation of the 
 main trunk immediately distal to the aneurysm, no branch intervening 
 (Hodgson, 1815) (Fig. 211); while the ''new operation" of Wardrop 
 (1828) involves ligation of one of the main branches below the sac, 
 or of the parent trunk below the origin of a })ranch (Fig. 212). These 
 methods are inferior to proximal ligation, because less certain; but 
 are still employed in places where the proximal side of the artery is 
 
 Fig. 211. — Brasdor's method of liga- 
 tion for aneurysm, applied for aneurysm 
 of the common carotid artery (C). I, 
 innominate; S, subclavian artery. 
 
 Fifi. 212. — Wardrop's method of liga- 
 tion for aneurysm, applied for aneurysm 
 of the innominate (/). The common 
 cartoid (C), and the subclavian (S) in its 
 third portion have been ligated, permit- 
 ting slight circulation through the thy- 
 roid axis. 
 
 inaccessible, as in Innominate Aneurysm, or large aneurysms of the 
 first part of the Subclavian. For innominate aneurj^sm simultaneous 
 double ligation of the common carotid and subclavian arteries is 
 preferred, constituting Wardrop's method, since the subclavian is 
 tied in its third portion below^ the origin of the thyroid axis and 
 vertebral. 
 
 Double Ligation, Above and Below the Sac. — When this is immedi- 
 ately followed by incision of the aneurysm, evacuation of the clots, 
 and packing of the sac, to control hemorrhage from collaterals entering 
 the sac, it constitutes the operation of Antyllus (third century, a.d.); 
 if the sac is opened first, the clots evacuated, the mouth of the sac 
 
256 SURGERY OF THE BLOOD VASCULAR SYSTEM 
 
 sought with tlie finger, and a probe passed up and down the parent 
 trunk as a guide to the appHcation of Hgatures above and below 
 the tumor, it constitutes the "old operation," which was temporarily 
 revived by Syrae QSoT). 
 
 At the present time the mortality from ligation is about 8 per cent.; 
 there is, however, also the risk of gangrene, requiring amputation, 
 which occurs in an additional S per cent, of cases (Delbet). Gangrene 
 is due not only to sudden arrest of the circulation, but also to pressure 
 on surrounding tissues by the thrombosed sac, and sometimes to 
 embolism of the artery below the sac. E\en if a patient recovers 
 and escapes gangrene, the symptoms from pressure (neuritis, edema, 
 etc.), may be not only unrelieved but even aggravated by solidifica- 
 tion of the sac. 
 
 FiLiPi-xcTURE AXD Electrolt.sis; Wirinx. of Axeurysms. — 
 Wiring was intrcxluced by Moore (1864), and modified by Corradi 
 (1879) who passed an electric current through the wire coil. Fine 
 gold or silver wire fXo. 28 gauge) is used, being inserted through a 
 cannula which is plunged into the aneurysmal sac; from ten feet to 
 as many yards of wire are introduced; the positive pole is attached 
 to the wire entering the aneurysm (Hare, 1908), the negative pole 
 being placed elsewhere on the patient's body, and the current (70 
 to SO milliamperes) is allowed to run for nearly an hour. This method 
 may be attempted in certain cases of internal aneurysm in which 
 death is imminent from rupture, or in which Tufnell's treatment 
 (p. 253) (perhaps combined with repeated venesection — ^^'alsalva's 
 method) fails to relieve urgent pressure s\Tnptoms, but in which liga- 
 tion or endo-aneurysmorrhaphy are impossible. Thoracic aneurysms 
 (aortic arch, low innominate) are to be localized by physical exami- 
 nation and the ^-ray, and the camiula plunged directly into the sac; 
 abdominal aneurysm is treated after exposing the sac by laparotomy. 
 For thoracic aneurysm no other surgical treatment is possible, except 
 in the case of innominate aneurysm, when simultaneous double distal 
 ligation is preferable. In some cases of abdominal aneurysm endo- 
 aneurysmorrhaphy can be performed, and is preferable if temporary 
 control of the circulation can be secured. ^latas (1900) found that 
 wiring and electrolysis resulted m apparent recovery in less than 20 
 per cent, of cases; in 1910 he condemns the method as a '"pureex- 
 p>eriment, which is justified solely by the imminent and unavoidable 
 danger of death from the progress of the disease itself." Eshner 
 (1910) has analyzefl 36 cases of aneurysm, mostly aortic, treated by 
 wiring; 9 patients died within ten days, 22 lived less than one year, 
 and 5 survived for periods ranging from fourteen months to over 
 eleven years. 
 
 ExTiRPATiox OF THE Sac, known by the names of Philagrius 
 (third century A. D.), and Purmann (1685), now finds an ardent 
 supporter in Delbet. It removes the danger of gangrene due to pres- 
 sure on surrounding parts by the clot-filled sac, as also the danger of 
 embolism. For its successful performance it is necessary to secure 
 
T RE ATM EST Ob' AMCIUYSM 
 
 lot 
 
 preliininan' control of the circulation, when possible Ijy iij)plication 
 of an elastic hand at the root of the linil), or even hy direct clamp- 
 ing of the afferent and efferent artery. This latter method, however, 
 may not prevent profuse recurrent hemorrhaj^e from collaterals 
 empty inj^ into" the sac. The vein should be ])reserved, and if impor- 
 tant structures are adherent to the sac that jxtrtion of the sac should 
 be left behind. According to Delbet (19U7), among 8() patients 
 treated by extirpation of the sac there were no deaths, and gangrene 
 followed in less than )> per cent. 
 
 Vu:. 21.i. 
 
 -Obliterative cndo-aneurysni- 
 orrhaphy. 
 
 Fig. 211. — Restorative endo-anciirysm- 
 orrhaphy. 
 
 Fig. 215. — Reconstructive endo-ancurysmorrhaphy. 
 
 Endo-axeurysmorril\.phy, introduced by ]\Iatas in 1888. After 
 controlling the circulation, the sac is opened: (1) If a fusiform 
 aneurysm, or a saccular aneurysm with very large mouth (Fig. 207), 
 is found, the sac is obliterated by a series of fine chromic catgut or 
 silk sutures, approximating its walls, and occluding the lumen of the 
 17 
 
258 SURGERY OF THE BLOOD VASCULAR SYSTEM 
 
 artery adjacent to the mouth of the sac {Ohliicrative Endo-aiiriiri/stuor- 
 raphy (Fig. 213). (2) If a saccular aneurysm with small mouth is 
 found, it may be possible to suture the margins of the sac mouth with- 
 out occluding the lumen of the i)arent artery (Fig. 214). Orifices of 
 collaterals are then sutured, and the sac walls approximated as before 
 {Restorative Endo-aneurysmorrhaphy) . (3) In rare cases the form of the 
 aneurysm may be such that it will be possible to reconstruct l)y suture 
 a channel to represent the lumen of the parent artery, though little or 
 no evidence of such a channel exists when the sac is opened; a soft 
 catheter may be used as a guide (Fig. 215) (Reconstructive Endo- 
 aneurysmorrhaphy or Aneurysmoplasty .) 
 
 The methods of ]\Iatas possess over ligation all the advantages of 
 extirpation (less mortality and diminished risk of gangrene) while at 
 the same time they entail less trauma than extir])ation, and in the 
 restorative and reconstructive methods atl'ord the possibility of 
 preserving the circulation through the parent artery; and even if 
 this circulation is preserved only temporarily, gangrene is less likely 
 than if the circidation is occluded immediately as in extirpation. 
 If endo-aneurysmorrhaphy is applied to cases of traumatic aneurysm, 
 this should not be until a firm-walled adventitious sac has formed. 
 Matas in 1910 collected reports of 110 cases of endo-aneurysmorrhaphy 
 (including 67 aneurysms of the lower extremity), with only two 
 deaths (1.8 per cent.) attributable to the operation, and 4 cases of 
 gangrene (3.6 per cent.), 3 of which were chargeable to complications, 
 not to the operation itself. 
 
riTAPTKR XL 
 
 SURGERY OF THE SKIN, BURS.^^], LYMPHATICS, 
 .MLSCLES, TENDONS, AND NERVES. 
 
 SURGERY OF THE SKIN. 
 
 Verruca or Wart. — This is a localized hyperplasia of the epidermis, 
 and theoretically may be distinjiuished from a jKipiUoma, which, 
 as noted at j). IIS is a neoplasm. The fa\'orite sites for warts are, 
 the hands, face, scalp, and neck. They iisnally apj)ear to grow spon- 
 taneously, but in a few cases a suspicion of contagion exists; trauma 
 followed by moisture seems a predisposing cause. They show little 
 tendency to enlarge, scarcely ever become malignant, and occasionally 
 disap])ear from no apparent cause. Treatment is sought for dis- 
 figurement, sometimes for pain. Removal is accomplished easily 
 by snipping off the warts with scissors, after spraying with ethyl 
 chloride; the base is then cauterized with silver nitrate. Or by apply- 
 ing a drop or so of fuming nitric acid every few days, the warts will 
 in time shrivel up and fall oft' painlessly. Recurrence is rare after 
 thorough removal. 
 
 Venereal warts are those growing upon the genitals or around the 
 anus; they are due to irritation from uncleanliness, and have no 
 necessary connection with any venereal disease. 
 
 Callositas or Tyloma is a dift'use hypertrophic condition of the 
 skin, normally present to a slight degree in the palms and soles, 
 and due to intermittent pressure. It becomes of surgical interest 
 when the hypertrophy is so great as to cause the lesion to approach 
 to that of Claxus or Corn: in this lesion (which frequently develops 
 in the centre of a callosity, or may arise independently, especially 
 on the toes) the intermittent pressure causes a pyramidal shaped 
 up-growth of epithelial cells, which presses upon and finally separates 
 the papilke of the skin, and causes exquisite pain from pressure on 
 the highly sensitive nerve-endings found in this layer. A soft corn 
 is distinguished from a hard corn by the fact that the former is placed 
 where its surface is kept warm and moist, as between the toes; while 
 the hard corn develops on an exposed surface. When of long duration 
 a bursa may be formed beneath the corn, constituting a bunion; 
 this is most often the case over the metatarso-phalangeal articulation 
 of the great toe, often being combined with hallux vahiiis (p. 549). 
 
 Treatment. — Treatment of corns consists in removal of the cause; 
 in frequent bathing; application of such plasters as will relieve the 
 corn from pressure; use of salicylic acid ointment (5 to 10 per cent.); 
 
260 
 
 SURGERY OF THE SKIN 
 
 Fig. 216. — Hypertrophy of toe-nail, or 
 onychauxis, one year's growth since the 
 nail was last cut off. Episcopal Hospital. 
 
 paring the surface of the corn (a frequent cause of celluHtis, angeio- 
 leucitis, and sepsis, if carelessly done); and sometimes in formal 
 excision. 
 
 Cornu Cutaneum or Horn, is a rare affection of the skin, most 
 frequent in old age, and about the face; it may follow the spontaneous 
 
 evacuation of a wen. Closely 
 analogous to it is the condition 
 of hypertrophy of toe-nails or 
 onychauxis (Fig. 210). Excision 
 is the best treatment. 
 Keratosis Senilis. — See p. 022. 
 Onychia. — Onychia or inflam- 
 mation of the matrix of a nail is 
 classed as simple and malignant. 
 The former, or "run-around," is 
 most frequent in children, starting 
 from a hang-nail, and appearing as a red, swollen, tender semicircle 
 around the base of the nail. Treatment consists in application of anti- 
 septics, with incision as soon as suppuration is suspected. Malignant 
 onychia is a severer form of the disease, occurring in persons much 
 debilitated, and often coming under observation only in the stage 
 of ulceration ("toe-nail ulcer"); any portion of the nail remaining 
 should be removed, the granulations curetted or cauterized, and 
 the part dressed with stimulating ointments. Hygiene should be 
 attended to, and tonics prescribed. Amputation of the phalanx may 
 be necessary if necrosis occurs. 
 
 Ingrowing Toe-nail. — Ingrowing toe-nail, seen almost exclusively 
 in the great toe, usually is due to ill-fitting shoes, which produce a 
 degree of hallux valgus (p. 549) : in the early stages the form of the 
 nail is unaltered, but the soft parts of the pulp are crowded over 
 on its edge, and injudicious trimming of the nail down' this chink 
 predisposes to ulceration. Later, the edge of the nail becomes folded 
 under, and by pressure on the pulp, aggravates the condition. If 
 palliative treatment be persisted in long enough, a cure usuall\' may 
 be produced by keeping the parts free from pressure, and separating 
 the overhanging skin from the nail either by antiseptic cotton stuffed 
 into the chink, or by drawing the skin aside by adhesi^'e plaster, 
 while the ulcer is treated by desiccating powders after cauterizing 
 its base. The nail should be cut square across the top, and never 
 trimmed down at the sides. If a rapid cure is demanded, it is best 
 to avulse the side of the nail affected (both sides if necessary) by 
 splitting the nail down the centre with strong scissors, and grasping 
 the portion to be removed in forceps. Local anesthesia is sufficient. 
 Tytler (1909) applies a tight ligature around the base of the toe 
 until it is congested, then lightly crushes with forceps the affected half 
 of the nail; in a day or so it becomes soft and bluish, and may be cut 
 away with scissors. As the new nail grows, properly fitting shoes must 
 be worn to prevent recurrence. 
 
CARBUNCLE 261 
 
 Perforating Ulcer. -Pcrfo rati 11^2; ulcer, usually seen in the sole 
 of the toot or uii(l(T tlu- <;rfat toe, occurs in those ])ast middle life, 
 and is connected with arterio-sclerosis or tro])hi(,' disturbances. It 
 occurs in diabetes, and in locomotor ataxia, and ]>robably is not a 
 specific disease, but merely an evidence of tissue destruction due 
 to malnutrition. It is not attended by much pain, may follow slij^ht 
 injury, frost-bite, etc., and frecjuently originates in a small slouf^h 
 in the centre of a callosity or corn. If untreated, the ulceration 
 steadily progresses, eating through the foot, involving muscles, 
 tendon, and bone; is attended by a stench, and in advanced stages 
 jH'rforates the dorsum of the foot. Under hygienic measures, internal 
 administration of potassium iodide, rest in bed, and active local 
 treatment (cleansing, curetting, etc.), temporary cure sometimes is 
 obtained. 
 
 Furuncle or Boil. — Furuncle or boil is an infection of a hair follicle 
 or sebaceous gland, confined to the deeper layers of the true skin, 
 usually terminating in suppuration, with the extrusion of a central 
 slough called the core. The usual cause is Staphylococcus aureus, 
 which gains entrance through a minute abrasion, as from a rough 
 edged collar or cufl". Persons with disordered metabolism (diabetes, 
 gout, nephritis, scrofula, eczema, etc.), are especially predisposed to 
 furunculosis. The classical symptoms of inflammation are present — 
 a red, extremely tender and painful swelling, attended by local heat, 
 in the true skin and subcutaneous tissues. Boils vary much in size, 
 but seldom appear over tw^o inches in diameter; they usually are 
 multiple, sometimes appearing in successive crops. Boils usually 
 have a marked tendency to point; those that do not, are called "blind 
 boils." 
 
 Treatment. — Treatment includes such general hygienic and tonic 
 measures as will prevent a continuance or recurrence of the boils; 
 frequent bathing, with the use of alkalies (sodium carbonate) in the 
 bath and by mouth, is important. By local treatment in the \ev\ 
 early stages it sometimes is possible to abort a boil by pouring pure 
 ichthyol oxev its surface, and making a scab with a film of absorbent 
 cotton. In most cases, however, early incision, besides relieving pain, 
 will accelerate extrusion of the slough, and prevent formation of 
 neighboring boils, which are encouraged by poulticing. After extract- 
 ing the core, pure ichthyol may be poured into the crater of the 
 furuncle, or a drop of carbolic acid may be introduced on a match- 
 stick. The surrounding skin must be kept clean and stimulated with 
 astringent washes. In cases of persistent furunculosis, much benefit 
 has been derived from the administration of autogenous ^'accines. 
 
 Carbuncle. — Carbuncle may be regarded as an aggravated form of 
 boil (Fig. 217). The infection spreads more wideh^ in the subcutaneous 
 tissues, there is phlegmonous inflammation, and the pus tends to 
 e^'acuate itself through manifold orifices, by following the course of 
 the columnw adiposop (Warren, 1881). Carbuncles are most common 
 on the nucha, and may extend almost from the vertex to the shoulder. 
 
262 
 
 SURGERY OF THE SKIN 
 
 In the old, the diabetic, the subjects of advanced Bri<;ht's disease, 
 etc., it forms a very serious malady, often endanyerinu; life. There 
 
 is no clear limit to the inflam- 
 mation, which usually is more 
 widespread than is apparent 
 on the surface. 
 
 Treatment. — Hygienic and 
 constitutional treatment is even 
 of more \alue than in furun- 
 culosis. (1) Small carbuncles 
 should be treated as boils, by 
 early incision which may be 
 crucial if necessary, to facilitate 
 extrusion of the sloughs. (2) 
 Medium-sized carbuncles should 
 be incised as above, and then 
 strapped with adhesive plaster 
 applied concentrically, until 
 only a small orifice is left for 
 the discharge of pus (Fig. 218) ; 
 this strapping, suggested by 
 O'Ferral (1858) and emphasized 
 as particularly valuable by J. 
 Ashhurst, Jr. (1809), acts 
 mechanically by [limiting -^the 
 spread of the phlegmon by erecting an impassable barrier around 
 the base, and forcing the discharge of sloughs through the central 
 
 Fig. 217. — Carbuncle of neck; duration, 
 two weeks; incised a few days ago; no im- 
 provement. Episcopal Hospital. 
 
 
 1 
 
 
 1 
 
 ^^^^B V 
 
 
 
 ^^^H 
 
 ^^^V "^ 
 
 % 
 
 ^'^^^H 
 
 1 
 
 ^^^^V^;^ 
 
 
 
 ^H 
 
 HP^ 
 
 x\ 
 
 
 ^^1 
 
 
 \ 
 
 vM^^^^I 
 
 ^^^^H 
 
 F\:f\>:- 
 
 
 ^^ 
 
 1 
 
 Fig. 2 is. — Carbuncle of neck 
 strapped with adhesive plaster. Epis- 
 copal Hospital. 
 
 Fig. 219. — Carbuncle of u'.'ck after .strap- 
 ping for one week. Only a suj^erncial ulcer 
 remains. Episcopal Hospital. 
 
 opening; it secures local rest; and also, I believe, creates a certain 
 degree of passive hyperemia in the diseased area, thus increasing the 
 
Lcrcs vrijLMus 2(;:5 
 
 pliM^ocv tic and (t|)s<>iiic jxjwcrs of the ])ati('iit. The stra|)|)iii^' cliccks 
 almost at once the excessive pain caused l»y tlic carhuncle, and as 
 it nia.\ l)e left in i)lace for several days at a time, consi(leral)ly 
 simplifies the treatment. The gauze which receives the discharf^e 
 throuj:;h the central oj)enin<i: should he chanj^ed daily. 'J'he dimi- 
 luition in size of the carhuncle (I'ig. -\\)) evident when the 
 strappinjf is removed is as remarkable as it is gratifying. Seldom 
 more than two or at most three straj)pings are required to convert 
 an angry volcano into a sui)erficial ulcer, which readily heals under 
 i)Iand ointments. ['.\) W'ry large rarhintrles sometimes may be excised, 
 with benefit: the patient being anesthetized, a circular incision is 
 made at the apparent outer border of the carbuncle; this incision 
 is carried down to the deej) fascia and muscles, which rarely are 
 involved, and the entire sloughing mass is cut away; l)leeding, which 
 may be profuse, is checked by ligature, pressure, or cauterA'; and the 
 large raw surface is packed with absorbent gauze, which should not 
 be removed for four or five days. Free stimulation is required after 
 the oi)erati<)n, and skin-grafting may be necessary to secure final 
 cicatrization. 
 
 Tuberculosis Cutis. — The tuberculous lesions of the skin of most 
 interest to surgeons are Luyus Vulqaris, Scrofuloderma, and Erythema 
 Indnratiim. 
 
 Lupus Vulgaris. — The tuberculous lesions are seated in the corium, 
 and usually are secondary to an insignificant focus elsewhere. The 
 disease occurs in young persons of scrofulous tendencies, is most 
 frequent in the face, and appears as one or several minute red papules, 
 tender but not appreciable to touch, which on examination are found 
 to be covered by a thin pellicle of altered skin, giving them, when 
 the blood is pressed out by application of a glass slide, a close resem- 
 blance to drops of apple-jelly. The overlying pellicle is soft and easily 
 punctured, the probe or scalpel sinking for some millimeters into 
 the diseased area. These nodules may coalesce, the patch spread- 
 ing eccentrically and healing in the middle, and thus bearing some 
 resemblance to certain of the syphilodermas; but the apple-jelly 
 nodules can be seen in the advancing border of the lupus patch. 
 \Yhen lupus ulcerates (lupus exedens, as distinguished from simple 
 lupus, or lupus non-exedens), the surrounding tissues may be widely 
 destroyed, but the ulcer ahvays remains superficial; its outline is 
 rounded, its edges are not indurated, and its course is verv slow 
 (Figs. 220 and 221). 
 
 Diagnosis. — This must be made by careful examination to detect 
 the apple-jelly nodules, by attention to the clinical history of the 
 patient, and by exclusion of syphilis, epithelioma, or other rarer 
 ulcerations of the skin, all of which usually occur in older patients. 
 Lupus erythematosis, thought by many to be due to toxins of tubercle 
 bacilli lodged elsewhere in the body, is sufficiently characterized by 
 its usual butterfly outline, its persistent redness, the absence of the 
 apple-jelly nodules, and its unulcerated condition. 
 
264 
 
 SURGERY OF THE SKIN 
 
 Treatment. — The treatment includes constitutional anti-tu})erculous 
 measures (p. .S2), and local remedies. The latter, whenever possible, 
 should consist of excision, replacing the loss of tissue by skin-grafting 
 or a plastic operation (p. 023). If excision cannot be done, the 
 diseased spots should be gouged out with a sharp spoon, and the 
 cavities left treated with strong antiseptics or caustics, lladiography 
 is of value in some mild cases, as is the use of radium, Finsen 
 light, etc. \ 
 
 i'u;. L'L'O.- l.upus vulgaris in a girl, aged 
 sixteen years. Four years ago the first 
 lymph node swelling appeared under the 
 chin. There followed tuberculous lym- 
 phangeitis, which involved the skin. Two 
 years ago invasion of nasal mucosa oc- 
 curred, and this led to involvement of the 
 skin over the nose. (Philippson.) 
 
 Fig. 221. — Lupus vulgaris of face, in 
 a woman, aged thirty-eight years; the 
 disease began twenty-three years ago in 
 the left cervical lymph nodes. (Phil- 
 ippson,) 
 
 Scrofuloderma. — Scrofuloderma is the name given to the tuber- 
 culous lesion of the skin which results when this is invaded by a 
 tuberculous process in an underlying structure, as a caseous lymph 
 node. The condition was referred to at p. SO, Fig. 36. 
 
 Erythema Induratum or Bazin's Disease (1855) is a paratuber- 
 culous affection usually of the calves of the legs of growing girls 
 with a scrofulous taint; it appears as multiple bluish-red indurations, 
 resembling somewhat both furuncles and syphilitic gummas, which 
 tend to soften and discharge, leaving indolent and very painful 
 ulcers. These can be made to heal only by improving the general 
 health. 
 
 Erythema Nodosum. — Erythema nodosum is mentioned merely 
 to w^arn the student not to mistake its lesions for contusions or 
 abscesses. The affection usually is bilateral, occurs in children, and 
 
SEIiACKOrS CYST 
 
 205 
 
 in most casrs tlic shins arc aflVcted (Fi^. 222), tliouj^'li sonu'tiincs 
 t\\v U'sions ajjpear over the sul)C'utanc()Us surfaces of the uhuc. There 
 is no history of trauma; tlierc is more constitutional disturbance than 
 from bruises; and often the 
 (Hscase is one manifestation 
 of an infection (jnThaps some 
 attenuated form of tubercu- 
 K)sis) which causes endocar- 
 ditis, ])Icurisy, etc. 
 
 Acne Rosacea. — See p. fi20. 
 
 Epithelioma. — See j). (■)24. 
 
 Sebaceous Cyst (Steatoma, 
 Wen). — This is a retention 
 cyst, due to occlusion of the 
 orifice of a sebaceous duct. 
 The cysts, which may be 
 
 Fig. 223. — Sebacc-MU.- i\,~t mI -raljj; (iuratioii, 
 thirtj' years. Episcopal Hospital. 
 
 f * 
 
 
 ^^m ' 
 
 Fig. 222. — Erythema nodosum. 
 One week's duration, following 
 staphylococcic infection of finger 
 and complicated by endocarditis. 
 Temperature, 100.4° F. Episcopal 
 Hospital. 
 
 Fig. 224. — Scbaceou.s cyst of ear. Episcopal 
 Hospital. 
 
 multiple, occur mostly in the scalp and face (Figs. 223 and 224); 
 on the extremities, and especially below the level of the umbilicus they 
 are extremely rare. The skin is adherent to the cyst at one point, the 
 orifice of the duct, sometimes visible as a black dot; the cheesy, malo- 
 dorous sebum usually can be squeezed out, after inserting a probe into 
 
2()() 
 
 IXJURIES AXD DISEASES OF BURS.E 
 
 the duct. These cysts frequently become hiflamed and su})])urate; 
 when thev discharge spontaneously, a bleeding fungous mass ])rotrudes 
 which may be mistaken for a malignant papilloma; and carcinomatous 
 changes are not unknown (p. 553) . If the discharge of sebum crusts 
 on the surface, a cutaneous horn (p. 260) may develop. Some seques- 
 tration cysts (p. 130) are clinically indistinguishable from sebaceous 
 cysts (Fig. 220). 
 
 Fig. 225. — Sebaceous cyst of 
 ear excised. (See Fig. 224.) 
 
 Fig. 226. — Dermoid cyst of scalp. Children's 
 Hospital. 
 
 Treatment. — Wens are removed easily, under local anesthesia, 
 by dividing the overlying skin and dissecting the unruptured sac 
 from the subcutaneous tissues, to which its adhesions are light. 
 Recurrence is frequent unless all the cyst wall is removed. If of 
 large size some of the overlying skin may be excised. 
 
 Pilo-nidal Cysts and Fistulae. — These are a form of sequestration 
 cysts, mentioned at p. 130. They occur most often in the region of 
 the anus, and may be congenital or acquired. According to Hodges 
 (1880) only the sinus is congenital, and the hairs work their way in 
 during post-natal life, finally occluding the orifice of the sinus and 
 forming a cyst. Suppuration is frequent. Excision is the proper 
 treatment (Klemm, 1909). 
 
 INJURIES AND DISEASES OF BURS^. 
 
 Wounds of Bursae. — If the bursa opened communicates with a 
 joint, serious consequences may follow; and as, in the case of a bursa 
 which sometimes communicates with a joint, the fact of its non- 
 communication can never be known a priori, all such cases should 
 be treated as if a joint was involved (p. 386). If the wound is 
 punctured, it should be enlarged, after suitably cleansing the part; 
 and foreign matter should be extracted, the bursa drained, and local 
 and constitutional rest provided. If no infection follows, the bursa 
 will heal with partial or complete obliteration of its cavity. If 
 suppuration occurs, daily irrigation of the bursa should be done as 
 
BURSITIS 
 
 2()7 
 
 soon as it is r\i(l(Mit that no profiress toward iK-aliiifi is hciii^- inaile 
 iiKTelx l)y draiiia.iit'. l''iiiall\ , the bursa may he excised if coiitimiaiice 
 in eoiiser\ati\e treatiiu-nt is inell'ectiial. 
 
 I'k;. 227. — Pioiiatcllar Inusiti.s: two 
 months' duration; subacute onset. Epis- 
 copal Hospital. 
 
 Fig. 22 >. — Olccianon Inn. sit is, two 
 months' duration; no acute trauma. Epis- 
 copal Hospital. 
 
 Bursitis. — Bursitis, or inflammation of a bursa, usually follows 
 contusions, and may be acute or chronic. Acute bursitis follows 
 slight continuous, or frequently intermitted trauma, as in the retro- 
 calcaneal bursa {Achillodynia or Albert's disease, 1893), or in the 
 
 olecranon bursa in those confined to bed, 
 with gouty tendency. Relief of pressure, 
 evaporating lotions, and rest, usually cause 
 subsidence of the inflammation in a few 
 hours. If suppuration occurs, early free 
 incision should be made. Chronic Bur- 
 sitis, which follows slight but continually 
 repeated trauma, may be a sequel of 
 acute bursitis or may be chronic from 
 the start. The bursae most often af- 
 fected are: (1) Prepatellar ("Housemaid's 
 Knee," Fig. 227); (2) Olecranon ("Miner's 
 Elbow," Fig. 228); or (.3) the bursa over 
 the Tuber Ischii ("Weaver's Bottom"). 
 
 Fig. 229. — InHanimation of 
 bursa beneath tendo iiatella?, 
 bulging on inner side of tendon. 
 Acute onset three days ago, from 
 acute flexion of knee. "Dis- 
 persed" by a blow. Episcopal 
 Hospital. 
 
 Fig. 230. — Ganglion in bursa of biceps brachii at 
 insertion. Episcojial Hospital. 
 
268 INJURIES AND DISEASES OF THE LYMPHATICS 
 
 Other bursts sometimes aflFected are: (4) Siil)acromial Bursa (see 
 Periarthritis, \). 4(i6); (5) that beneath the Tendo Patellae (Fig. 
 229) ; (6) those over the Femoral Condyles (see Ganglion of Popliteal 
 Space, p. 281); (7) Subgluteal Bursa; (8) that over the head of the 
 first metatarsal bone (see Bunion, p. 259, and Hallux Valgus, p. 549); 
 (9) between the tendon of the Biceps and tuberosity of the Radius 
 (Fig. 230). By coagulation of the effused fluid, solid enlargement 9f 
 a bursa may occur. 
 
 Treatment. — Treatment of chronic bursitis consists in removal 
 of the cause, application of sorbefacient ointments, painting with 
 tincture of iodin, etc.; and, these failing, in tapping and injection 
 of 2 per cent, formalin-glycerin solution or dilute alcohol (never when 
 joint-communication may exist), in incision and drainage (when 
 healing will occur by obliteration of the sac), or in excision which 
 is best in most cases, especially those of long duration with thick 
 sac walls. 
 
 INJURIES AND DISEASES OF THE LYMPHATICS. 
 
 Wounds. — Wounds of the lymphatics are of little moment escept 
 when the thoracic duct is injured, as it may be in operations on the 
 neck. If this accident is discovered when the wound is inflicted (by 
 a discharge of milky fluid in the wound — lymiihorrhea) , an attempt 
 should be made to apply a lateral suture. If this is impossible, 
 both ends of the duct should be ligated; and this failing, the wound 
 should be tamponed. If the injury is not discovered at the time of 
 operation, it soon makes itself manifest by a discharge of chyle from 
 the wound, and by rapid and progressive emaciation. There should 
 be no delay in reopening the wound and suturing or ligating the 
 duct. Fredet (1910) collected 58 cases of injury to the thoracic 
 duct, with five deaths. 
 
 Lymphorrhea. — Lymphorrhea may also occur from wounds of 
 lymphangiectases (p. 2()9), 
 
 Chylothorax and Chylous Ascites occasionally follow rupture from 
 contusion of the thoracic or abdominal portions of the thoracic duct. 
 Repeated tapping of the thoracic or abdominal fluid has resulted in 
 cure in a few cases. Certain chylous cysts of the mesentery (Chapter 
 XXIII) have a similar origin. Chyluria may result from communica- 
 tion with the urinary tract. 
 
 Lymphangeitis or Angeioleucitis, inflammation of lymphatic vessels, 
 usually is due to spread of infection from a wound. It is seen most 
 often on the extremities, but I have seen it on the abdomen as a result 
 of omphalitis. There are one or several flame red, irregular streaks 
 running from the site of infection (felon, lacerated woimd, etc.) up 
 to the axillary or inguinal lymph nodes; these streaks coalesce here 
 and there to form broader red bands, and may again separate before 
 reaching their terminus (Plate I, Fig. 1). They are not particularly 
 painful or tender, seldom are palpable, and are redder and less regular 
 
L YMF II A NGIECTA SIS 
 
 2G9 
 
 in tlioir course than veins in cases of plilehitis (p. '2'M)). There is 
 considerable fever, cliills may occur, and lymphadenitis usually 
 co-exists. Treatment consists in cure of the focus of infection; in 
 local rest by si)lints, confinement to bed, etc., and in applications of 
 silver nitrate, dilute iodin, ichthyol, etc., along the course of the 
 inflamed lymphatics. Su])])uration frecpiently occurs in the lymph 
 nodes, but seldom along the lym])h vessels. 
 
 Lymphadenitis. Lymj)hadenitis, or simply "adenitis," occurs as 
 an incident in cases of lymj)hangeitis, but may also occur when no 
 evidences of superficial lymphangeitis exist. 
 Thus femoral or inguinal adenitis (bubo) 
 frc(|uently follows a blister of the foot, or 
 venereal or other infection of the genitals, 
 when no sign of lymphangeitis can be de- 
 tected (Fig. 231). Epitrochlear or axillary 
 adenitis may arise from a slight abrasion or 
 pimctured wound of the hand which healed 
 before the secondary lesion was noticed. 
 The symptoms are those usual in inflam- 
 mation, and the tender, enlarged lymph 
 nodes are distinctly palpable. Suppuration 
 is not unusual. Secondary invasion by 
 specific microbes (chancroidal, tuberculous) 
 may occur, and somewhat changes the 
 character of the lesion. Any lymphadenitis 
 which assumes a subacute or chronic course 
 is liable to infecton with tubercle bacilli 
 through the blood-stream. This is espe- 
 cially true of cervical adenitis (p. 676). 
 Chancroidal bubo is discussed in Chapter 
 XXVI. 
 
 Treatment. — Treatment of adenitis im- 
 plies cure of the source of infection; anti- 
 phlogistic applications to the seat of 
 
 adenitis ; early incision in case of suppuration ; and finally formal exci- 
 sion of the diseased mass of lymph nodes if the resulting sinus fails 
 to close under conservative treatment or if the lymph nodes remain 
 enlarged and tender without the occurrence of suppuration. 
 
 Lymphangiectasis. — Lymphangiectasis, or dilatation of lymph 
 channels, results from obstruction to the flow of lymph. This may 
 be due to external pressure (as from tumors or cicatrices); to 
 operative removal of the nodes draining the part; or it may be 
 caused by chronic lymphangeitis, causing obliteration of the main 
 lymph vessels, often following repeated attacks of erysipelas, etc. 
 It is much rarer as a consequence of external pressure than is 
 phlebectasis (p. 242), because the lymphatic collateral circulation 
 is much freer. Sometimes it affects the spermatic cord, constituting 
 a lymphatic varicocele. When a distinctly localized swelling is formed, 
 
 Fig. 231. — Femoral lymph- 
 adenitis; duration, two days; 
 from infected wound of left foot 
 two weeks ago. Episcopal 
 Hospital. 
 
270 INJURIES AND DISEASES OF THE LYMPHATICS 
 
 it is known as Ii/mphancjeionia; this occurs oftenest as a congenital 
 condition in the face or neck, but may develop in adult life (Fig. 232). 
 It forms a soft fluctuating swelling, covered by healthy skin. 
 Excision is the proper treatment, but if complete extirpation is im- 
 possible, a partial operation entails great risk of lymphorrhagia, 
 with malnutrition; in such cases galvano-puncture may be tried. 
 Macromelia, or giant growth of a part, usually is a lymphangeio- 
 matous condition; one finger, the lips, the tongue, etc., may be 
 affected. 
 
 Fig. 232. — Lymphangeioma of right 
 foot, aged seventy-five years; duration, Fig. 23.3. — Lymphedema: duration, one 
 seven years. Orthopedic Hospital. year. Episnopal Hospital. 
 
 Lymphedema, resulting from lymphangiectasis, and consisting of 
 thickening of the subcutaneous tissues from the effused fluid with 
 cellular reaction, occurs principally in the lower extremity (Fig. 233), 
 often associated with chronic ulcer; or in the upper extremity follow- 
 ing ablation of mammary carcinoma and axillary lymphatics (Fig. 
 744). Ilereditary persistent edema of the legs, w^hich has been studied 
 by Jopson (1898), is believed by Hope and French (1908) to be a 
 vascular neurosis, causing hard edema, which terminates abruptly at 
 the knee or groin, there being no evidence of venous or lymphatic 
 obstruction; but the result is very like lymphedema. If palliati^'e 
 treatment (bandaging, massage, etc.) fails, various operative measures 
 may be undertaken. Excision of wedge-shaped longitudinal strips 
 of the thickened skin and cellular tissues may reduce the bulk of 
 the limb so as to promote ease in locomotion. Lymphangeio plasty 
 (Handley, 1908) consists in inserting long strands of silk in the sub- 
 cutaneous tissues from the hand or foot to the axilla or groin; these 
 act as capillary drains and rapidly reduce the edema. Lanz (1911) 
 drilled holes into the medulla of. the femur and inserted into them 
 strips of fascia lata still attached by one end, thus creating new 
 
ii()J)(;kl\'s disease 
 
 271 
 
 duimu'ls of (Iniinii^c tlironuli i\\v iniirn»\v caxity. Aiii))nt;iti(tii is tlic 
 last resort. 
 
 Elephantiasis Arabum is a form of lympliedenia duv to ohstniction 
 of lyinpli clianiu'ls hy filaria ffanoNi'nl.s homijii.s, the disease l)einf; 
 called filaridsis. The ])arasite is transferred from patient to patient 
 through a ni()S((iiito as intermediary host. In the ])atient the half 
 grown parasites l()d<i;e in the })eripheral lynii)hatics, th<'re heeome 
 matnre and ])r()dnee ()lfs])ring. The emhryos enter the hlood-stream, 
 bnt ap])ear in the ])eripiieral circnlation only at niyht; when the 
 
 Fig. 234. — Persistent hereditary edema af- 
 fecting two brothers. (See Fig. 235.) (Dr. 
 Jopson's cases). Children's Hospital. 
 
 Fig. 235. — Persistent hereditary 
 edema, in two brothers. (See Fig. 
 234.) (Dr. Jopson's cases). Chil- 
 dren's Hospital.) 
 
 patient is at rest they are readily abstracted thence by the mosquito. 
 Elephantiasis afl'ects the lower extremities and the scrotum more 
 often than other parts of the body. It is rare in this country, except 
 in persons recently returned from the tropics. Treatment: Palliation 
 is secured by support, bandaging, etc., but excision usually is indi- 
 cated. Amputation may be necessary. 
 
 Hodgkin's Disease (1832) (Malignant Lymphoma, Lymphomatosis, 
 etc.). This, according to Adami, is a condition of the lymph nodes 
 comparable to keloid in the skin — "an excessive overgrowth of the 
 lymphoid stroma secondary to a minimal or unrecognized irritation." 
 The disease was referred to in the chapter on Tumors (]). 114); it 
 
272 
 
 IX JURIES AXD DISEASES OF THE LYMPHATICS 
 
 Fig. 236. — Hodgkin's 
 disease affecting the neck 
 and both axillae. (Dr. J. 
 Ashhurst, Jr.'scase.) Uni- 
 versity Hospital. 
 
 appears to occupy a place midway between the infectious granu- 
 lomas and pure tumors. Sometimes it resembles tuberculosis of 
 lymph nodes (tuberculous infection may be secondary), at others it 
 approaches lymphosarcoma in type. A number of observers have 
 found in the affected lymph nodes a Gram-staining, non-acid-fast, 
 polymorphous diphtheroid bacillus. 
 
 Symptoms. — It afl'ects young adults, especially males, becoming con- 
 spicuous first in the neck, as a diffuse, bilateral, hyperplastic lymi)li- 
 atic enlargement (Fig. 23()). The axillary, 
 inguinal, abdominal, and thoracic nodes are 
 subsequently affected ; even the spleen becomes 
 enlarged. The masses are not inflammatory 
 in character; do not adhere to the skin; the 
 individual nodes remain discrete a long time; 
 suppuration is unknown; enlargement is pro- 
 gressiA'c, though temporary remissions may 
 occur. Severe anemia accompanies the dis- 
 ease; the patient is feverish, listless, becomes 
 dyspneic, weak, emaciated, and dropsical. 
 There is no hyperleukocytosis, the only 
 marked blood change being reduction in the 
 amount of hemoglobin. The most distressing 
 symptoms are those due to pressure of the 
 immense masses in the neck and mediasti- 
 num, and it is for such effects only that 
 surgical treatment, consisting in excision, is demanded. The disease 
 tends under all circumstances to a fatal termination, the duration in 
 most cases being measured by months rather than years. Excision 
 of portions of the mass for diagnosis and prognosis often is done, as 
 the lesions present a typical histological picture — endothelial pro- 
 liferation, giant and eosinophile cells. Treatment by vaccines made 
 from the bacillus mentioned above has been attempted by Billings 
 and Rosenow (1913) with rather encouraging results. 
 
 Lymphosarcoma. — Lymphosarcoma was referred to at p. 114. 
 Theoretically we may distinguish (1) True Lymphosarcoma, from 
 sarcomatous proliferation of the connective tissue cells of a lymph 
 node; (2) Malignant Lymphoma, from malignant proliferation of 
 lymphocytes in the lymph node; and (3) Lymphoma Sarcomatodes, 
 indicating secondary (anaplastic) sarcomatous change in the lympho- 
 cytes of a benign lymphoma (p. 114). The distinction is difficult 
 histologically and impossible clinically. 
 
 The disease may occur in the mediastinum or neck; tends to spread 
 locally, to ulcerate, and to produce death by pressure, hemorrhage' 
 or cachexia; internal metastases (liver, lung) may occur early, due to 
 the invasion of veins by the original tumor; involvement of other 
 groups of superficial lymph nodes is very unusual. 
 
 1 The hemorrhagic sloughing ulceration constitutes one form of the Fungus 
 nematodes of the older writers. 
 
WOUNDS OF MUSCLES 27:'. 
 
 Diagnosis. I )ia^ni()sis is (iifficiilt: it nuiy he distiiij^uislifd from 
 Ilod^'kiii's disease by tlie rapid growth (weeks rather tluui months), 
 the imihiteral rather than hikiteral involvement, tlie tendency to 
 uk'eration. and the i)ersistently kx-al character until the last stages; 
 from fiihrrriiloyis of li/)iij)li nodes by the greater firmness, and absence 
 of caseation and suppuration even when ulceration has occurred. 
 Treatment is of little avail; excision should be attempted, especially 
 to relieve pressure effects; but complete removal is difficult and recur- 
 rence usually is i)romi)t. 
 
 Carcinoma of Lymph Nodes is secondary to a primary focus else- 
 where. So-called primary carcinoma of lymph nodes really is an 
 endothelioma. 
 
 INJURIES AND DISEASES OF MUSCLES. 
 
 Wounds of Muscles — Little more need be said of these than wiiat 
 is contained in the discussion of wounds in general (p. 105). Sutures 
 
 do not hold very firmly in mus- 
 cular tissue alone; therefore 
 mattress sutures are used, and 
 in the case of transverse division 
 of the muscular fibres the over- 
 lying fascia (muscular sheath) 
 is included in the sutures when 
 possible. The cicatrix formed 
 I \ / / in a muscle max somewhat 
 
 fe 
 
 Fig. 237. — Diagram roprfsciiting a ca.se (<f 
 extensive rupture of the abdomiual wall com- 
 plicated by fracture of the iliac crest. The 
 shaded area indicates the extent of the re- 
 sulting hematoma. (See Fig. 2.38.) Episcopal 
 Hospital. 
 
 Fi(i. 2'.iH. — Rupture of abdominal 
 wall and fracture of pelvis, after opera- 
 tion. (See Fig. 237.) Episcopal Hos- 
 pital. 
 
 impair its contractility, but the disability is slight unless the scar 
 is adherent to the skin or bone. 
 18 
 
274 
 
 INJURIES AND DISEASES OF MUSCLES 
 
 The sheath of a muscle may be ruptured by external injury (con- 
 tusion) or by violent muscular contraction; the belly of the muscle, 
 when contracted, will then protrude through the rupture, constituting 
 a muscular hernia. Some forms of ventral hernia (Fig. 772) are of 
 this nature. The diagtiosis is based on the history of trauma and the 
 appearance of an abnormal protrusion only when the muscle contracts; 
 sometimes when the muscle is relaxed the aperture in its sheath is 
 palpable. The condition may be simulated by an intermuscular 
 lipoma. Treatment consists in suture of the rent. 
 
 Rupture of a Muscle, much rarer than rupture of its tendon (p. 278), 
 usually results from violent muscular contraction, without external 
 injury. The abdominal muscles, however, may be ruptured sub- 
 cutaneously by a crushing accident (Fig. 237). The lesion is sub- 
 cutaneous, and when due to muscular action alone occurs oftenest 
 in patients with rheumatic or fibrotic tendencies. When a long 
 muscle, such as the biceps brachii or quadriceps femoris, is affected, 
 there is a distinct hollow perceptible between the retracted ends, 
 and this becomes more evident during voluntary contraction. Func- 
 tional impairment may be marked. 
 
 Treatment. — Treatment consists in suture of the muscle and its 
 sheath. 
 
 Myositis. — Myositis, or inflammation of a muscle, is frequent in 
 rheumatism and as the result of contusions. Septic myositis occurs 
 
 by invasion from a neighboring focus (bone, 
 joint, lymph node), or as a metastatic 
 infection; it also follows typhoid fever. 
 In such cases the ordinary symptoms of 
 inflammation are present, and suppura- 
 tion, with extrusion of sloughs {necrotic 
 masses, p. 58), is the rule. In traumatic 
 myositis the muscle becomes swollen, 
 painful, tender, and of almost wooden 
 hardness (Fig. 239). Suppuration is very 
 unusual. 
 
 Treatment. — Treatment comprises rest, 
 i I^^^B S with application of sorbef acient ointments ; 
 
 i ^^^^^ ■ anti-rheumatic remedies internally may 
 
 I ^^^^^^ ■ relieve pain. Acupuncture and wet cup- 
 I . j^^^^^^L ■ P^^S ™^y ^^ tried. Massage is beneficial 
 
 when acute symptoms subside. Meta- 
 static abscesses in muscle require prompt 
 evacuation. 
 
 Myositis Ossificans occurs in two forms, 
 
 the stationary and the progressive. 
 
 1. Myositis Ossificans Traumatica, the stationary form, is due to 
 
 injury, usually following sprains, luxations, repeated slight contusions, 
 
 etc. If small fragments of periosteum have been detached, it is 
 
 possible that these may cause bony growth in the muscles or tendons 
 
 Fig. 239.— Myositis of left 
 quadriceps femoris; unknown 
 cause; duration, five weeks. 
 Aged fifty-three years. Epis- 
 copal Hospital. 
 
M YDS I TIS OSSIFICA NS 
 
 'It I) 
 
 siirrouudiiit; ;i joint; but it is held by sonic that tlie niusclu ceils 
 themselves or those of the perimysium may produce l)one. The 
 disease occurs in the adductor muscle of the thi^h ("rider's bone"), 
 in the deltoid from shouldering a musket, in the brachialis anticus 
 (Fig. 240) following dislocation of the elbow, in the tendo Achillis 
 following sprains, etc. The diagnosis rests on a history of injury, and 
 on the existence of a localized, tender, hard, more or less movable mass 
 in the body of a muscle or tendon. The a:-ray usually is necessary 
 to confirm the diagnosis. Proper treatment is excision of the bony 
 mass, unless this shows a tendency to retrogress spontaneously when 
 the i)art is ])ut at rest. 
 
 Fig. 240. — Skiagraph of myositis ossificans traumatica. New-formed bone in 
 brachialis anticus muscle. Aged twenty-one years. Episcopal Hospital. 
 
 2. Myositis Ossificans Progressiva is an obscure affection, perhaps 
 due to auto-intoxication, l^eginning in the first ten years of life and 
 progressing slowly "with intervals of quiet, death occurring in ten 
 or twelve years — either from some intercurrent disease, especially 
 bronchopneumonia, or from inanition due to involvement of the 
 masseter muscles." (W. Walker, 1908.) The thumbs and great toes 
 usually have a congenital deformity {microdactylia) consisting in 
 shortening of the metacarpal or metatarsal bones, sometimes with 
 ankylosis of the phalanges (Fig. 241). The muscles oftenest affected 
 are in the trunk, the upper extremity, and the neck, especially tlie tra- 
 
276 
 
 I. \J CRIES AXD DISEASES OF MISCLES 
 
 pezius, latissimiis dorsi, sterno-mastoid, and shoulder muscles (Vi^. 242) . 
 
 The disease betrins with soreness and stiffness in the affected muscles, 
 
 attended by local cyanosis and doughi- 
 ness. After weeks or months another 
 exacerbation occurs, and finally bony 
 masses become palpa})le and demon- 
 strable by the .r-ray. No treatment 
 has been of any avail. 
 
 Contractures of Muscles resulting 
 ill limitation of articular motion (false 
 ankylosis), follow rheumatic, gouty, 
 or other inflammations, but are of 
 special interest to surgeons in cases 
 of infantile palsy or patients with 
 bone and joint disease. ^Yeight ex- 
 tension, the use of a Stromeyer splint, 
 elastic traction, massage, passive 
 motion, etc., sometimes are efficient 
 in overcoming the deformtiy. but not 
 infrequently mobilization under anes- 
 thesia, or myotomy and tenotomy are 
 
 required. If the joint capsule is the seat of contracture it may have 
 
 to be incised also. CSee Figs. 243 and 244.) 
 
 Fig. 241. — Microdactylia in a 
 case of myositis ossificans progres- 
 siva. (Dr. Warren Walker's case.) 
 Children's Hospital. 
 
 Fig. 242 
 
 -Myositis ossificans pnjgressiva showing deposits in muscles of back. 
 (Dr. Warren Walker's case.) Children's Hospital. 
 
 Ischemic Contracture (see p. 540). 
 
 Trichiniasis. — Ingestion of the embryos of trichina spiralis, a 
 parasite infesting uncooked pork, is followed by their migration to 
 and development in the muscular tissues. Within a week or ten 
 days after eating the contaminated food, the patient is attacked 
 with muscular soreness, widely distributed, which frequently is 
 regarded as rheumatic. Diarrhea often is present, and fever is usual. 
 Examination of the blood shows eosinophilia (even as high as 50 
 
WOUNDS OF TENDONS 277 
 
 per cent.). Microscopical exuiiiiiiatioii of excised imisciilar tissue 
 confirms the diaj^nosis. Beyond purgation, treatment is of little 
 value; and the duration of the disease appears to be self limited 
 to a few weeks. 
 
 I.F1G. 243. — Contractures of ilio-psoas muscles following neglected case of Pott's 
 disease of spine. Children's Hospital. 
 
 Tumors of Muscles. — Rhabdomyoma and leiomyoma have been 
 discussed at p. 114. Desmoids are tumors growing from muscle or 
 fascia, usually of the abdominal wall, analogous to keloids in the 
 
 Fig. 244. — Contractures of feet, following paralysis of extensor muscles from fracture 
 of tenth and eleventh thoracic vertebrse, five years previously. Episcopal Hospital. 
 
 skin. They usually are single, oftenest arise after pregnancy or in 
 an operative cicatrix, and sometimes recur after extirpation, assuming 
 sarcomatous characteristics. 
 
 INJURIES AND DISEASES OF TENDONS. 
 
 Wounds of Tendons. — Wounds of tendons are of frequent occur- 
 rence, and often are followed by marked disability, owing to adhesion 
 of the tendons to their sheaths, to each other, to the skin, to bone, 
 etc., even if careful primary suture has been done. Tendons retract 
 when divided, and the surgeon must not hesitate to enlarge the 
 original wound to find the divided ends. Usually it is better to 
 administer a general anesthetic, especially in wounds of the flexor 
 tendons above the wrist. ]\Iattress sutures are preferable, and if the 
 ends cannot be made to meet, tendon lengthening may be emploved 
 (Fig. 2G4). 
 
278 
 
 INJURIES AND DISEASES OF TENDONS 
 
 Subcutaneous Rupture of Tendons is more frequent than that of 
 their muscidar l)ellies. Usually it occurs only in already slightly 
 diseased tissues, especially in cases of periarthritis (p. 4()()), dystrophic 
 arthritis, etc. Following a sudden strain, the patient is conscious 
 of something giving way, perhaps with an audihle snap; severe 
 
 Fig. 245. — Rupture of long head of biceps brachii, forty-eight hours after accident, 
 from violent contraction while leading unruly horse by halter. Dr. G. G. Davis's 
 case. Orthopaedic Hospital. 
 
 stinging pain occurs, and the part is disabled. Ecchymosis appears 
 subsequently, and when the affected muscle is voluntarily contracted, 
 a characteristic deformity is seen, owing to the loss of attachment 
 of the tendon. The biceps brachii, especially its long scapular head, 
 (Fig. 245), and the quadriceps femoris are often affected; rupture of 
 one of the tendons of the extensor longus 
 digitorum near its insertion in the finger 
 is not unusual (Fig. 24(i). So-called rup- 
 ture of the plantaris probably is not 
 as frequent as supposed (p. 243). In 
 the phalanges, firm bandaging on a 
 splint for several weeks may prevent 
 permanent deformity or disability; in 
 other cases the affected tendon should 
 be sutured. 
 
 Fig. 246. — Rui>turp of tendon of extensor 
 longus digitorum to fifth finger; from fall on 
 hand two months ago. Episcopal Hospital. 
 
 Fig. 247. — Luxation of pero- 
 neal tendons in front of external 
 malleolus of left foot, following 
 paralytic calcaneus. Orthopaedic 
 Hosjjital. 
 
 Dislocation of Tendons may be pathological or traumatic. The 
 former is more frequent, and is secondary to changes in the contour 
 of the neighboring joints, or to peri-arthritic lesions causing obliter- 
 
I'MiONVdllA OR PANARIS 270 
 
 atioii ol" llic iiMtural tiTooxc in wliicli tlic tendon lies. In ciises of 
 int'iintilc ]);iriil\sis witli marked caleani'iis detoriiiity the pcroncdl 
 t('ii(lu)is may hv luxated anterior to the external malleolus (Fi^- 247); 
 in i-ases of knock-knee or sim])le relaxation of tissues around the knee- 
 joint, oiifirard lu.vdfloii of the jxifflla may occur; in peri-artiiritis of 
 the shoulder, iiiirdnl dislocation of flic long head of the biceps sometimes 
 is seen, allowinj;- a subluxation forward of the head of the humerus. 
 These deformities may he remedied by ojxTation if disability is 
 marked. Correction of any i)rcdis])()sint:; deformity is the first step. 
 In the case of the patella a suitable knee-caj) may give relief, or the 
 inner portion of the capsule may be pleated on itself, or the point 
 of insertion of the tendo patelhe may })e shifted inward. The capsule 
 of the shoulder may be })leated, and the biceps tendon shortened. 
 
 Strains of Tendons are of frequent occurrence. Minute extrava- 
 sations occur among the rujjtured fibres, and the tendon is swollen, 
 painful, and tender. Schanz (1005) has called particular attention to 
 traumatic inflanmiation of the tendo Achillis, which often is mistaken 
 for achillodynia (p. 207). Some cases of "trigger finger" (p. 543) 
 may have a similar origin. The treatment is rest during the acute 
 stage, followed by massage. 
 
 Tenosynovitis or Thecitis is the name given to a form of inflam- 
 mation of tendon sheaths usually caused by rejjeated trauma (strains), 
 in those predisposed to rheumatic conditions. It occurs oftenest 
 in the extensor tendons at the wrist, but is also seen at the ankle, 
 and elsewhere. There is a fine crackling and creaking, appreciable 
 on palpation and sometimes audible, whenever the affected tendons 
 are moved; this is caused by effusion of plastic lymph between the 
 tendon and its sheath. The disease never progresses to the stage 
 of suppuration. 
 
 Treatment. — Treatment consists in splinting the part and applying 
 ointments of ichthyol or of belladonna and mercury, iodin, etc. 
 Local rest should be insisted on until physical signs have been absent 
 for a week at least; otherwise recurrence is usual. With prompt 
 treatment work generally may be resumed in a few weeks. 
 
 Tuberculosis of Tendon Sheaths usually is secondary to tuber- 
 culous synovitis or arthritis (p. 477). See also Tuberculous Ganglion, 
 p. 281.' 
 
 Paronychia or Panaris. — This is a rather vague term, denoting 
 a septic inflammation about the flexor surface of the finger tips 
 (very rarely of the toes). (1) Digital Abscess: The mildest form is 
 an abscess in the pulp of the finger, not involving tendon or bone. 
 Incision in the long axis of the finger evacuates the pus and leads to 
 rapid healing. (2) If the tendon sheath is involved the affection is 
 known as ivhitloiv. In the thumb and fifth finger such inflammation 
 (arising from a pin prick, abrasion, hangnail, run-around (p. 260), 
 etc.), may spread readily to the palmar bursa, with which the sheaths 
 of these tendons usually are continuous, forming jKilmar abscess 
 (Fig. 248). The finger tip becomes extremely painful, tender, throb- 
 
2Rn 
 
 INJURIES AMD Dh'^EAMm OF TENDONS 
 
 bing, and swollen. The patient speilcb a sleepless night; poultices 
 bring little relief; inflammation spreads up the tendon sheath, and 
 the whole finger is swollen to two or three times its natural size. 
 Occasionally a whitlow will evacuate itself if ])oulticed long enough 
 (Fig. 241)), but proper treatment consists in very early free incision, 
 
 Fig. 248. — Palmar abscess ; duration, 
 one week; showing ineffectual incisions 
 made three days ago. Episcopal Hos- 
 pital. 
 
 Fig. 249. — Whitlow; spontaneous rup- 
 ture; duration, eleven days; untreated. 
 Children's Hospital. 
 
 into the tendon sheath, and the application of hot moist antiseptic 
 dressings, with suitable splint and sling. At later stages local or 
 general anesthesia may be necessary, with numerous counter-openings 
 and tube drainage, or antiseptic irrigation. After proper incisions, the 
 continuous bath is especially useful. Only when incision is done at 
 the earliest stage can sloughing of the tendon be prevented: the 
 tendon receives its vascular supply through 
 delicate reflections of the synovia, and very 
 slight swelling within the tendon sheath 
 is sufficient to obliterate this circulation. 
 If the tendon sloughs the incision will be 
 
 Fig. 2.51. — Bilocular ganglion 
 Fig. 250. — Ganglion on extensor surface of wrist (see excised from wrist (see Fig. 
 Fig. 251). Episcopal Hospital. 250). Episcopal Hospital. 
 
 slow in healing, and a stiff finger will result. Healing of a chronic 
 sinus sometimes may be hastened by dressing it with mercurial 
 ointment. (3) If the periosteum or phalanx is involved, the disease 
 is known as a bone felon, but as the distinction from whitlow rarely 
 can be made before incision, and as treatment is the same, there 
 
a A NO LI ON 
 
 2X1 
 
 Is little use in niakiiifj; a separate sui)(li\isi()ii for felons. Excision 
 or am])utatioii may he necessary it" the i)lialan\ heconies necrotic. 
 
 Fic. 2.")2. — Tuberculous ganglion of right wrist and palm (hour-glass swelling). 
 Aged forty-two years; duration, five years. Orthoptedie Hos|)ital. 
 
 Ganglion. — A ganglion is a cyst developed in connection with a 
 tendon sheath, or from the snbsynovial tissues of a joint capsule. Its 
 pathogenesis is not well understood, but 
 probably is a degenerative change (Clarke, 
 1908). Frequently slight trauma has 
 occurred, but often no such history can 
 be obtained. Ganglia occur oftenest in 
 women, being especially frequent on the 
 extensor surface of the wrist (Fig. 250) ; 
 they are seen less often at the ankle or 
 in the palm of the hand (Fig. 252) and 
 certain bursal enlargements seem clini- 
 cally identical with ganglia (Figs. 230 
 and 253). Occasionally a ganglion con- 
 tains rice-like bodies, similar to "joint- 
 mice" (p. 478); and sometimes a gan- 
 glion is frankly tuberculous; this is 
 especially apt to be the case in "com- 
 pound ganglia," where the cystic mass 
 is more or less lobulated, possibly as 
 the result of the coalescence of several 
 distinct ganglia. 
 
 Treatment. — If operative treatment is 
 refused, a small ganglion may be dis- 
 persed by a smart blow with a heavy 
 book, the part being splinted subse- 
 quently for a week or so; recurrences 
 may be expected in over half the cases 
 so treated. Safer and better treatment 
 
 is aspiration and injection of 2 per cent, formalin glycerin solution or 
 of dilute iodin or alcohol; or formal excision of the ganglion. Tuber- 
 culous ganglia never should be treated by attempts at rupture. 
 
 Fig. 25.3. — Ganglia in popliteal 
 space; aged eighteen years; dura- 
 tion, over one year. Episcopal 
 Hospital. 
 
282 
 
 INJURIES AND DISEASES OF NERVES 
 
 INJURIES AND DISEASES OF NERVES. 
 
 Contusion. — Contusion of a nerve produces tingling and perhaps 
 numbness or paralysis in its distribution. A frequent lesion is i)aralysis 
 of the musculo-spiral nerve (less often of the circumflex) from pressure 
 
 Fig. 254. — Paralysis of musculo-spiral nerve from overlying. 
 
 during sleep (overlying) — most seen after a debauch, the patient having 
 lain stuporous for many hours (Fig. 254). In other cases the lesion 
 
 results from a sudden blow or fall, 
 perhaps from sudden abduction 
 of the humerus (Fig. 255). 
 Cridrh-pdlsy, affecting the axil- 
 lary nerves, especially the mus- 
 culo-spiral, is caused by the 
 patient bearing most of his weight 
 on the axilla instead of on his 
 hands, usually because the hand- 
 bars of the crutches are placed too 
 low. Post-anesthetic palsy is due 
 to direct pressure, the arm hav- 
 ing been allowed to hang over the 
 edge of the table (musculo-spiral, 
 ulnar) ; or from pressure on the 
 peroneal nerve below the head of 
 the fibula. This latter form of 
 paralysis may result from im- 
 proper application of a gypsum 
 case. As a rule, the only treat- 
 ment required is rest, followed by 
 massage, electricity, etc. Subcu- 
 taneous rupture is extremely rare, 
 but in compound fractures or 
 similar accidents a nerve may be 
 crushed, complete destruction of the nerve fibres occurring, and only the 
 sheath remaining to connect the bruised ends of the nerve. The signs 
 of loss of function due to such nerve injuries usually are subordinate 
 
 Fig. 2.5.5. — Paral.wsis of left circumflex 
 nerve with atrophy of deltoid muscle, 
 from sprain of shoulder five months ago. 
 Patient, aged sixty years, fell twenty-seven 
 feet. Episcopal Hospital. 
 
STRETCHING OR I.ACER ATION 
 
 2S3 
 
 to tliosr due to tlie lesions of the iiuisolos, tendons, and bones; l)ut in 
 all snch accidents the surfjeon shonld make tests lor sensation and 
 motion in tli(> i)ait supplied by any nerves which possibly might have 
 been injured. Kesection of the dania<;-ed jjortion, with end-to-end 
 union of the nerve stumps should be done, as described under WOiutd.s 
 of Nrnr.s' (p. 2X1). 
 
 Dislocation. — Dislocation of a nerve is rare. Occasionally the 
 ulnar nerve slii)s in front of the internal condyle, and causes moderate 
 disability. OptTation generally is necessary to replace such nerves 
 and consists in restoring normal relations and suturing a layer of 
 fascia over the nerve to hold it in place. 
 
 Stretching or Laceration. — Stretching or laceration of nerves is 
 not iufrccpient as a subcutaneous injury In dislocations or sprains 
 of the shoulder the circumflex, and more rarely the musculo-spiral 
 nerve, may thus be damaged; or 
 rarely the cords of the brachial 
 plexus may be injured. (See also 
 Neuritis, p. 287, and Periarthritis, 
 p. 4()6.) According to Vanden- 
 bossche (1910) it is probable that in 
 most of these latter cases the lesion 
 is in the nerve roots rather than in 
 the brachial plexus. Duval and 
 Guillain (1898) maintained that 
 there were no such clinical entities 
 as paralyses due to lesions of the 
 plexus, only two types existing, 
 radicular and terminal, affecting 
 either the spinal motor roots or 
 the nerve trunks below the plexus. 
 The usual cause of obstetrical 
 palsy (brachial birth palsy) is either 
 direct pressure on the plexus by 
 forceps in delivery (rare), or stretch- 
 ing and laceration from attempts to deliver a shoulder by injudicious 
 traction on the head, or in delivery of the after-coming head. The 
 usual deformity is characteristic (Fig. 256), due to paralysis of the 
 external rotator muscles; the hand is little affected, but supination and 
 flexion of the forearm are imperfect or entirely absent. This corre- 
 sponds to the "upper arm" type (Duchenne-Erb) of brachial paralysis, 
 the lesion being in the outer cord (i. e., fifth and sixth cervical nerves) 
 of the brachial plexus, involving especially the suprascapular and mus- 
 culo-cutaneous nerves (Fig. G36). The " lower arm" type and paralysis 
 of the entire extremity are rare. T. T. Thomas (1914) contends that in 
 most of these cases the nerve injurj^ is secondary to joint damage, and 
 that treatment of the latter is the main indication (see also Congenital 
 Dislocation of the Shoulder, p. 513). In brachial palsy the prog- 
 nosis is not very good, some disability usually persisting throughout 
 
 Fig. 256.— Braohial birth i>alsy f)f 
 the left arm. in a boy aged seventeen 
 months. Typical posture. Ortho- 
 psedic Hospital. 
 
284 INJURIES AND DISEASES OF NERVES 
 
 life, no matter what the treatment. Rupture of the nerve sheaths 
 occurs first, and there is more or less laceration of the nerve fibres 
 themselves; intra- and peri-neural hemorrhage occurs, with marked 
 cicatricial changes in the plexus and overlying cervical fascia. Trraf- 
 mctit. After a period of rest, until acute symptoms subside, strychnin 
 should be administered, and efforts made to improve the nutrition 
 of the muscles by massage, electricity, baths, etc. Should no further 
 improvement occur in six months or a year, operation must be con- 
 sidered. A. S. Taylor (1913) urges exploratory operation as soon 
 after birth as the general condition of the infant warrants; but his 
 results do not encourage imitation when it is remembered what great 
 improvement usually follows conservative treatment. After exposing 
 the plexus, it is dissected free from the cicatricial adhesions, irre- 
 trievably damaged segments of nerve tissue are excised, and the 
 stumps reunited or implanted into another nerve as described below 
 (p. 286). Alexinsky (1899) proposed transplanting the peripheral ends 
 of the damaged nerve roots to the opposite side of the neck, and 
 uniting them to the central ends on the other side; a similar operation 
 has been done by Babcock (1907), in a case of anterior poliomyelitis. 
 ^Muscle and tendon transplantation often will give better results than 
 any operations on the nerves. 
 
 Wounds of Nerves. — These may be an incident in extensive lacerated 
 wounds in\'olving muscles, tendons, and bloodvessels;, or isolated 
 
 injuries due to stab wounds (Fig. 257). 
 The symptoms are complete loss of func- 
 tion in the distribution of the injured 
 nerve; usually this implies loss of both 
 motion and sensation. If only a per- 
 ipheral sensory nerve is divided, sensation 
 may return in time, even if the ends of 
 the nerve are not sutured; this is due in 
 part to regeneration, and in part to col- 
 lateral circulation, as it were, in surround- 
 ing nerve filaments. But unless the ends 
 
 I'iG. 2.57. — Paralvsis of pero- p , i i j. • x 
 
 neai nerve following injury of ot a motor ucrvc are brought mto accu- 
 
 cauda equina in spinal anes- rate apposition bv SuturC, paralvsis of 
 thesia; seventeen months dura- • -n i ' ^ \ iv " j. 
 
 tion. Orthopcedic Hospital. motion Will be permanent. Alter suture, 
 
 the prognosis is uncertain, though if suture 
 is done soon after the accident {primary suture) more or less com- 
 plete recovery is the rule (Figs. 258 and 259); after secondary suture 
 the results are very uncertain (Figs. 260 and 261). 
 
 Howell (1892) collected 84 cases of primary nerve suture, with 
 42 per cent, successful results, and 40 per cent, improved; and 80 
 cases of secondary suture, with 38 per cent, successful, and 50 per 
 cent, improved. 
 
 Treatment. — The nerve should be exposed, and all damaged tissue 
 excised with a sharp knife. The cicatricial tissue must be excised until 
 the projecting ends of the nerve fibres can be seen in the cross-section. 
 
WOUNDS OF NERVES 
 
 285 
 
 Scissors bruise nervos, and never should he use<h The ends arc then 
 united (neurorrhaphy) with ver\' fine silk or elironiie catjiut threaded 
 
 Fig. 25S>. — Kccovcij- after primary suture of lausculospiral nerve, for stab 
 wound. Episcopal Hospital. 
 
 in ophthahnic needles. The sutures, some of which should be of the 
 mattress type, pass directly through the nerve, and are tied just 
 
 Fiii. 259. — Recovery of function after primary suture of musculospiral nerve 
 for stab wound. Episcopal Hospital. 
 
 tight enough to approximate without constricting the ends; a few 
 guy sutures should then be applied merely through the nerve sheath, 
 
 Fig. 260. — Stab wound of median nerve just after operation of secondary suture 
 (three months after injury) ; showing inability to flex wrist, index finger, and thumb 
 (see Fig. 261). (Dr. Harte's case.) Orthopaedic Hospital. 
 
 to relieve strain, and prevent adhesions of the nerve fibres to surround- 
 ing structures (Fig. 262). If for any reason, the ends of the nerves 
 cannot be made to meet (even by nerve-stretching and flexing neighbor- 
 
286 
 
 INJURIES AND DISEASES OF NERVES 
 
 ing joints), both ends may be implanted into a neighboring nerve trunk 
 (nerpe anastomosis) (Fig. 203), or neuroplasty may be done (Fig. 2(54). 
 A layer of muscle should then be 
 sutured over the nerve, to prevent 
 adhesion to the skin; the wound 
 should be closed; and the limb kept 
 at rest for two or three weeks, when 
 light massage, electro-therapy, etc., 
 
 Fig. 261. — Recovery of function eight 
 months after secondary suture of median 
 nerve (see Fig. 260). Note power of flexing 
 wrist, index finger, and thumb. (Dr. 
 Harte's case.) Orthopaedic Hospital. 
 
 Fig. 262. — Nerve suture. Two 
 mattress sutures have been inserted, 
 passing into the nerve substance, and 
 two sutures including only the sheath. 
 
 may be commenced. Sensation returns long before motion, sometimes 
 within a few days; but hope of motion should not be abandoned 
 
 \;j5^v; 
 
 Fig. 263. — Nerve anastomosis. A, the distal Fig. 264. — Neuroplasty. The 
 
 segment of the wounded nerve is sutured into a proximal segment is split and a flap 
 
 slit in a neighboring nerve; B, it is implanted in is turned down and sutured to the 
 
 a wedge-shaped incision. distal segment. 
 
NEURITIS 287 
 
 for about a year after suture, unless, of course, it can be sliown 
 that the sutures have given way. Under such circumstances the 
 ojxTation may be clone over ajjain. In all cases development of 
 deformity must be prevented by splints, braces, passive motion, 
 etc. Regeneration of sutured nerves dej)ends on the formation of new 
 axones, which some hold develop from proliferation of neurilemma 
 cells in the peripheral segment, while others maintain that in all 
 cases the axones grow out from the central segment, and have to 
 penetrate the distal segment to its various terminations before function 
 is restored. At present the weight of evidence appears to be in favor 
 of those upholding the former view (Ballance and Stewart, 1901), 
 and it is this teaching which justifies us in urging late secondary 
 suture; the axone is there, merely waiting to be joined to the cen- 
 tral segment. So long as the muscles have not become hopelessly 
 degenerated, nerve suture may be successful (after fourteen years, 
 Jacobson). Nerves which have no neurilemma do not regenerate; 
 the nerves of special sense have no neurilemma; nor have the soinal 
 nerves except peripheral to the spinal ganglia. 
 
 Neuritis. — Neuritis, as the term usually is understood, implies 
 not a reaction to septic infection, but a form of subacute or chronic 
 inflammation due to contusion, to pressure (from cicatrices, callus, 
 exostoses, tumors, etc.), to recurrent trauma {occupation neuritis), to 
 toxic infections (influenza, typhoid fever, etc.), intoxicants (alcohol, 
 lead, etc.), and other less well defined causes. The pathological 
 change is proliferation of the nerve sheath (epineurium, perineurium, 
 and endoneurium), which compresses the nerve fibres (axones), leading 
 to pain, impairment of function, and various trophic -disturbances in 
 the distribution of the affected nerve. The nerve trunk is hj-peremic, 
 perhaps edematous, swollen, and bulbous. Perineural adhesions are 
 frequently present. 
 
 Symptoms. — The onset may be sudden, after exposure to cold, 
 after violent exertions, or any factor which reduces the patient's 
 vitality. Pain is present in the portion of the nerve diseased, and 
 also shoots along the course of this nerve, usually in a peripheral 
 but sometimes in a central direction. There is tenderness along 
 the course of the nerve, and cutaneous hyperesthesia may be very 
 marked; numbness and a sense of swelling (vaso-motor or trophic 
 disturbances) may be present in the area of distribution. The skin 
 becomes glossy, appears tense and hyperemic; sweating usually is 
 diminished; incurvation or shedding of the nails may occur (Fig. 2(j5); 
 the muscles become atrophic and contractures and reactions of 
 degeneration may develop. 
 
 The nerve trunks most often affected are those of the brachial 
 plexus, the musculo-spiral, ulnar, and median, and the sciatic. It 
 must be remembered that the neuritis may be only a symptom of 
 another affection (periarthritis of -the shoulder, p. 466; ischemic 
 contracture, p. 540; sacro-iliac or hip-joint disease, p. 536; etc.). 
 
288 
 
 INJURIES AND DISEASES OF NERVES 
 
 Treatment.— Treatment comprises, first and foremost, removal 
 of the cause, whenever this can be discovered (calhis, tumor, cicatrix, 
 etc.). In all cases rest is of utmost importance, and should always 
 be the first step when no obvious cause exists. Counter-irritation 
 sometimes is of value. The patient's general health should be im- 
 proved. Antiseptics may be administered internally, especially the 
 salicylates. Electro-therapeusis, massage, and baking, are suitable 
 only' for the chronic stages, after rest has allayed the acuter symp- 
 toms. In many cases operation is of benefit (Fig. 2fifi), especially 
 neurolysis (dissection of the nerve trunk and even dissociation of its 
 fibres) ; neurectasy (nerve-stretching) is a less certain operation, though 
 aiming to accomplish the same results; neurotomy and neurectomy 
 (except when purely sensory branches are involved) seldom are justi- 
 fiable until other operations have failed. 
 
 F„, onr. _photo"-niijh showing Fig. 26G.— Photogriiph lundv ciKlit weeks 
 
 tnS;!^; ;h^n.S^g!>i\>ails as t after operation, to show !^-ven.n^ m 
 
 result of neuritis of median nerve. finger nails. (bee tig. 2b5.) i^pibcopai 
 
 January 31, 1907. Episcopal Hos- Hospital, 
 jjital. 
 
 Neuralgia.— Neuralgia, signifying pain in a nerve for which no 
 pathological lesion can be held accountable, remains an inscrutable 
 problem; and to state, as is often done, that such changes as may 
 be found on microscopical examination of the affected nerve are 
 the result, not the cause of the disease, in no way renders the subject 
 easier to understand. In a word, neuralgia is held to be a tunctional 
 
XKLh'ALClA OF Till': l-lFTll CJi'AMAL SKl{VI<: L^S•) 
 
 neurosis. Many cases of sii])iif)S('(l neuralgia, however, will he foniid 
 oil careful iuvestij^atiou to he due to referred jxi'ni from definite lesions 
 elsewhere. Many are reallx' cases of neuritis. 
 
 Symptoms. — Its symptoms differ somewhat from those of neuritis; 
 tlie ])ain is equally great, but may come and ^o without api)arent 
 cause; it is more l)urnin<:; and achinji; than sharp and shooting in 
 character; is more influenced hy damj) weather and exposure to cold; 
 and may he unattended with actual changes in the overlying tissues, 
 which are common in neuritis. The tenderness does not extend over 
 the entire course of the afi'ected nerve, but is most intense at certain 
 jioints ("])oints douloureux,") especially where the nerve passes 
 through a foramen (intervertebral, supra-orbital, mental, etc.), or 
 through the deep fa.scia; and pressure on the nerve with the palm of 
 the hand relieves rather than aggravates the pain, though pressure 
 by the finger tip or pointed instrument may bring on an exacerbation 
 of pain. 
 
 Treatment. — Treatment is much the same as for neuritis, which 
 often can be excluded from the diagnosis only after prolonged rest 
 has failed to give relief. Injections of cocain, alcohol, osmic acid 
 (1 per cent.), and other substances into or around the nerve have 
 been adopted in many cases with varying results (p. 290). Neu- 
 rectasis, neurolysis, and even neurotomy and neurectomy may be 
 done. 
 
 The forms of neuralgia most important to the surgeon are: 
 Neuralgia of the fifth cranial nerve; Brachial Neuralgia (which has 
 been sufficiently discussed under the heading Neuritis) ; and Sciatic 
 Neuralgia. 
 
 Neuralgia of the Fifth Cranial Nerve; Tri-Facial Neuralgia or Tic 
 Douloureux. — The pathology of this affection is very little under- 
 stood. Two types are recognized: the minor neuralgia, and the major 
 or epileptiform neuralgia. In the former, which probably is a true 
 neuralgia, there is more or less continuous pain, but it is not exces- 
 sively severe; usually some local or constitutional cause can be found, 
 and on remedying this the neuralgia may stop for a time or permanently. 
 Among such causes are caries of the teeth, sinus diseases, malaria, lead 
 poisoning, chronic nephritis, gout, etc. The major neuralgias, on 
 the contrary, appear to be due to some central lesion which involves 
 the Gasserian ganglion either primarily or by extension from disease 
 of its branches, or possibly by pressure from some intracranial growth. 
 This form of the disease is characterized by progressively severer 
 attacks of neuralgic pain, extending over months or years and affect- 
 ing one or more branches of the fifth cranial nerve, with no discover- 
 able cause. The mandibular and maxillary divisions are affected 
 in most cases; the supra-orbital branch rarely is affected alone. The 
 attacks may be brought on by a draft of air, by touching the side of 
 the face affected, by putting food into the mouth, etc. The skin 
 may become so hyperesthetic that for weeks or months the patient 
 may be unable to wash his face; he may be unable to eat because of 
 19 
 
290 INJURIES AND DISEASES OF NERVES 
 
 pain aroused in the lingual and inferior dental nerves; and a state 
 bordering on insanity may ensue finally unless relief is obtained. 
 
 Treatment. — It shoidd be ascertained whether any local or con- 
 stitutional cause for the neuralgia exists; and such conditions should 
 receive appropriate treatment. If the disease belongs to the major 
 neuralgia type no treatment will be of long avail unless it acts directly 
 on the nerves or ganglion itself. The administration of salicylates, 
 quinin, opium, or other drugs may be useful to allay the pain tem- 
 porarily and thus improve the general health before surgical treat- 
 ment is undertaken. This treatment implies destruction of the 
 nerves or the ganglion, or both. The operations are divided into 
 extracranial or peripheral operations and intracranial operations. 
 
 Peripheral Operations. — Injection of the nerve trunhs with alcohol 
 (Schlosser, 1907) has entirely superseded injections with osmic 
 acid, as originally advocated by Bennet in 1897. These substances, 
 especially alcohol, destroy the nerve at the point of injection, and 
 though regeneration may take place relief is secured for from six to 
 eighteen months, rarely for longer periods. The longest period of 
 relief secured in my own cases was just short of one year. Patrick, 
 of Chicago, has had large experience with alcohol injections, which he 
 makes into the second and third branches where they emerge from the 
 base of the skull, and into the first branch at the supra-orbital foramen. 
 He does not attempt to make deep injections into the first branch 
 because of danger to other structures in the orbit. He uses this 
 solution : 
 
 Gni. or c.c. 
 
 I^ — Cocain muriate 1 
 
 Alrohol ... 135 
 
 Aquae de-stillata; q. 8 ad 1.5 5 
 
 The internal maxillary artery with its branches, including the middle 
 meningeal, is directly in the field of operation and renders deep injec- 
 tions hazardous. But Patrick has had no bad results on this score 
 in 150 cases. The needle is 12 cm. long, 1.75 mm. thick, is not 
 acutely sharp, and is provided with a stylet. To inject the second 
 branch, the needle is inserted at the lower border of the zygoma 
 just in front of the coronoid process of the mandible (0.5 cm. behind 
 a perpendicular let fall from the posterior edge of the orbital pro- 
 cess of the malar bone); while the third division is reached from a 
 point at the lower border of the zygoma 2.5 cm. in front of its anterior 
 root, A tingling sensation in the distribution of the nerve indicates 
 that it has been reached. Usually the nerves must be sought for 
 cautiously b}' inserting the point of the needle in different directions. 
 The foramen rotundum lies about 5 cm., and the foramen ovale 
 about 4 cm. from the surface. About 2 c.c. of the solution are 
 injected into each nerve. "If the operator feels satisfied that the 
 needle is in the nerve (he never knows it)," writes Patrick, "less is 
 enough." No anesthetic is necessary. The injection may be repeated 
 in a few days if the first attempt pro^-es unsuccessful. If bleeding 
 
NEURALGIA OF THE FIFTH CRANIAL NERVE 291 
 
 occurs tlirou^'li tlic needle tlie stylet should be rej)l;iced and the 
 needle left iit ,sifu until clotting occurs; I punctured a large branch 
 in one case, but no bad effect was noted. 
 
 Anihion of ihe Peripheral Nerves (Thiersch, 1889) is a more 
 formidable procedure, and usually secures no longer freedom from 
 pain. The nerves arc very slowly avulsed ])y wra])])ing them around 
 a forceps, after adequate exposure. Not more than one complete 
 revolution of the forceps in every half minute should be made. The 
 su})ra-orbital nerve is exposed at the upper margin of the orbit; the 
 superior maxillary at the infra -orbital foramen, whence it may be 
 followed into the antrum of Highmore and along the floor of the 
 orbit; and the inferior dental branch is reached by trephining the 
 angle of the mandible. The lingual nerve may be reached at the 
 same time as the inferior dental by removing some of the ascending 
 ramus of the mandible (G. G. Davis, 1908). These nerves may be 
 avulsed both peripherally and centrally, from this location, but it is 
 well to avulse also the anterior portion of the inferior dental through 
 the mental foramen. 
 
 The second and third branches of the fifth ner\'e may also be 
 approached extracranially, at the base of the skull, by various routes, 
 involving more or less tedious and delicate operations. These methods 
 were employed chiefly before the general adoption of Thiersch's 
 method, when it was thought necessary to do a formal excision of 
 as much of the nerves as possible; they are now, I believe, very 
 properly abandoned. 
 
 Intracranial Operations. — Extirpation of the Gasserian ganglion 
 was proposed by INIears, of Philadelphia, in 1884, and first performed 
 by E. Rose in 1890. Rose employed the pterygoid route, trephining 
 the base of the skull. Hartley, of New York, and Krause, of Altoona, 
 independently in 1892 proposed the temporal route, and most surgeons 
 now employ some modification of the Hartley-Krause method. Owing 
 to the difficulty of removing the entire ganglion, from the presence 
 of adhesions and its intimate relation with the cavernous sinus, sixth 
 nerve, etc., many of the earlier operations were only partial excisions, 
 and well merited the description "bloody, difiicult, and dangerous," 
 which is still applied to them by Da Costa. To simplify the operation, 
 Abbe (1903), merely divided the second and third branches before 
 they left the skull, and interposed a strip of rubber tissue to prevent 
 their reunion. Spiller (1901) by a happy inspiration suggested to 
 Frazier that section of the sensory root of the ganglion would amount 
 to a physiological extirpation of it, since this root, which is devoid of 
 neurilemma, could not on that account regenerate. This operation, 
 as pointed out by Frazier, is easier, is attended by less hemorrhage, 
 does not expose the cavernous sinus or sixth nerve to injury, leaves 
 the motor root (and consequently the muscles of mastication) intact, 
 and, finally, involves a diminished risk of keratitis, which was so 
 prone to follow removal of the entire ganglion. 
 
292 I XJ CRIES AND DISEASES OF NERVES 
 
 Frazier-Spiller Operation. — A flap of soft parts is turned down, 
 care being exercised not to injure the upper branches of the facial 
 nerve. A sufficient amount of bone is then removed from the temporal 
 fossa, with trephine and rongeur, and the dura is raised from the 
 base of the skull. Frazier always ligates and divides the middle 
 meningeal artery, as it leaves the foramen spinosum. The bura 
 covering the mandibular division of the nerve is then incised, and the 
 ganglion exposed. If the motor root is seen, it should be separated 
 from the sensory; this latter is then divided or avulsed. The brain 
 is then allowed to fall back on the base of the skull, and the soft 
 parts are closed with drainage. The mortality following the operation 
 in the hands of skilled operators is less than 4 per cent. The chief 
 dangers are shock, hemorrhage, and infection. 
 
 After-care. — For weeks or months after operation the eye of the 
 same side should be most carefully protected by a shield (an automo- 
 bile goggle is suggested by Frazier), as destruction of its protecting 
 nerve supply renders the cornea exceedingly prone to trauma and 
 infection, and many patients have lost their sight from this cause. 
 
 Sciatic Neuralgia or Sciatica. — This is not regarded as so frequent 
 a lesion now as formerly, since it has been shown that in most cases 
 the disease really is a neuritis, or is merely referred pain due to pelvic 
 (Fig. 582) or hip disorders. If no cause of referred pain can be dis- 
 covered, and if rest, antirheumatic drugs, counter-irritation (blistering, 
 cauterization), and other palliative methods are ineffectual, the surgeon 
 may be tempted to adopt operative measures, on the theory that the 
 affection really is a neuritis, from infection or trauma, with perineural 
 adhesions. 
 
 Xeuredasis may be secured without incision by forcibly flexing the 
 thigh on the abdomen with the knee fully extended (the patient being 
 anesthetized) ; or by exposing the sciatic nerve below the gluteus 
 maximus, either on the inner or outer side of the biceps muscle, and 
 stretching it over the finger both centrally and peripherally; the 
 patient lying on his face it is safe usually to employ traction sufficient 
 just to raise the limb from the table. Xcurolysis is a safer and more 
 certain operation; the sheath is opened and the nerve fibres separated 
 from it and from each other for a distance of several inches; Pers 
 (1908) has adopted this method 47 times, and among 42 uncompli- 
 cated cases there were only three recurrences. In many cases the 
 adhesions extend up into the sciatic notch, and the completion of 
 the operation may be difficult. Best exposure is secured by splitting 
 the fibres of the gluteus maximus at the level of the great sacrosciatic 
 foramen. 
 
 Tic Convulsif or Spasmodic Tic is a form of neuralgia, usually not 
 painful, characterized by constant and often severe twitching in the 
 muscles supplied by the aft'ected nerves. In the neck, which is its 
 most frequent seat, it produces spasmodic torticollis; it also occurs 
 in the face, the shoulder, and very rarely in other parts of the 
 body. ^Myotomy, neurectasis, neurotomy, and neurectomy have been 
 
TUMORS OF NEIiVES 293 
 
 employed, but tlie disease always recurs in other muscles, no matter 
 how wide the primary nerve excision may have l)een. Some neurolo- 
 gists go so far as to maintain that even were the cortical centres 
 governing the region to be excised, neighboring centres would take 
 on diseased action. At present cure of the disease seems hojx'less 
 by operation, tiiough the temporary imjjrovement usually secured is 
 not to be despised. 
 
 Tumors of Nerves. — Fibrous out-growths sometimes occur on the 
 ends of nerves in an ami)utation stump ("amputation neuromas"), 
 apparently due to attenii)ts at regeneration: the nerve fibres turn 
 back upon themselves, being unable to make headway forward, and 
 form painful bulbous masses, which usually have a strong tendency to 
 recur if excised, or even after formal re-amputation. Such growths are 
 rare except where the amputation was a l)ungling ()j)eration. jMultiple 
 tumors occasionally are formed along nerve trunks or at the ter- 
 minations of nerve fibrils in the skin. This disease is variously known 
 as multiple neuro-fihromatosis (when confined to nerve trunks); 
 von Recklinghausen's disease (1881) or inoUusciim fihrusum (when 
 occurring in the skin); and Uanhenneurom or ylexijorm neuroma, 
 which occurs in the form of a circumscribed thickening of the skin, 
 due to out-growth of nerve fibrils — a condition most often found 
 in the neck or scalp, sometimes pigmented, and usually congenital. 
 Da Costa (1910) compares the condition of nerves in a plexiform 
 neuroma to that of the arteries in a cirsoid aneurysm. This disease, 
 in its various forms, usually has been considered a form of difi'use 
 fibromatosis, blastomatoid in character; but in the second edition 
 of his Pathology (1910) Adami returns to v. Recklinghausen's original 
 theory, and to that of Klebs (1889), which lately has received support 
 from other observers, that these growths originate in the nerve 
 fibrils themselves, and should be classed as Neurinomas. Excision 
 of one or several of the multiple growths may be required for pain or 
 deformity: those on the nerves sometimes may be shelled out with- 
 out destroying the continuity of the nerve trunk. The "plexiform 
 neuroma" sometimes recurs after removal; sarcomatous changes may 
 occur, though they are not very frequent. 
 
CHAPTER XII.5 
 P^RACTURES. 
 
 The study of fractures is one of the most important subjects which 
 can engage a surgeon's attention; they are injuries which occur 
 constantly, in all classes of life, and under all circumstances. Even 
 a general practitioner cannot avoid having a number of cases under 
 
 his care every year; and no cases 
 contribute as much to the fame 
 or discredit of the man who treats 
 them. And while it is well recog- 
 nized that the most skilful and 
 assiduous treatment cannot in 
 all cases succeed in giving the 
 patient a useful and comely 
 limb, yet it is sadly true that 
 many of the bad results con- 
 stantly seen are due to sheer 
 ignorance and neglect on the 
 part of the practitioner. 
 
 Classification. — Fracture of a 
 bone may be complete or incom- 
 ylete. The latter form {green- 
 stick fracture) occurs almost 
 exclusively in young children, 
 the bone fibres in the line of 
 extension (convexity) being com- 
 pletely ruptured, while those in 
 the line of flexion (concavity) 
 maintain their continuitv (Fig. 
 2()7). 
 
 Fractures may be subcuta- 
 neous {simple) or open {com- 
 jjound), the latter term implying 
 that the seat of fracture com- 
 municates with the external air 
 through a wound of the soft 
 parts. 
 Comminuted fractures are those with more than two fragments, the 
 lines of fracture intercommunicating (Fig. 208). They are to be dis- 
 tinguished from double {triple, quadruple, etc.) fractures in w^hich two 
 (or more) separate and distinct breaks are present in the same bone. 
 
 Fig. 267.- — Green-stick fracture of radius 
 and ulna with extreme deformity. Penn- 
 sylvania Ho.spital. 
 
CI.ASSIFICATION 
 
 21)-) 
 
 M ullij)!)' fiuK tiirr ( Fi<;-. 2(»U) is a term wliicli should he reserved for 
 eases with hreaks in more than one hone, the hones aU'eeted not heing 
 parallel (liUe the rihs, those of the forearm, the le^', hand, ete.). 
 
 Complindcd fractures are those 
 attended l)y some other serious 
 injury of ihc sumc part, as rupture 
 of the main hhxxhessels, erushin^ 
 of nerves, disloeation of neighbor- 
 ing joint, etc. A fracture of the 
 lower end of tlie femur may be com- 
 plicated by a fracture of the skull, 
 or by a stab wound of the hmg, but 
 such a fracture is not a "compli- 
 cated fracture of the femur" un- 
 less the popliteal artery is ruptured, 
 the knee-joint dislocated, or some 
 other serious injury exists in the 
 immediate neigliborhood of the 
 fracture. 
 
 Fio. 268. — Comminuted fracture of 
 tibia and fibula, a few hours after in- 
 jury. Episcopal Hospital. 
 
 Fig. 269. — Multiple fracture of upper 
 extremity. Episcopal Hospital. 
 
 Direction.— Fractures are further classified as longitudinal, trans- 
 verse, oblique, spiral, etc. These terms are self-explanatory^ and ^are 
 illustrated in the accompanying skiagraphs (Figs. 270, 271, 272). 
 Transverse fractures are more frequent in cancellous bone, and when 
 
296 
 
 FRACTURES 
 
 occurring in the shafts of long bones usually are due to direct violence; 
 whereas ol)lique and spiral fractures, seen almost exclusively in the 
 shafts of the long bones, generally are due to a twisting force trans- 
 mitted from a distance; and longitudinal fractures, freciuently extend- 
 ing into a joint, usually are caused by a splitting action. A depressed 
 fracture is one seen almost exclusively in the skull, in which the 
 fragments are displaced b>' the vulnerating force below the level of 
 
 the surrounding bone. An 
 impacted fracture is one in 
 which one fragment is driven 
 into the other, and remains 
 fixed (Fig. 306). Subperios- 
 teal fracture is one in which 
 the })eriosteum wholly or in 
 great part remains unrup- 
 tured. 
 
 Epiphyseal Separations. — 
 The epiphyses, or articular ex- 
 tremities of the long bones, 
 may be detached from the 
 shafts (diaphyses) by separa- 
 tion along the epiphyseal line 
 until the age when ossifica- 
 tion is complete in the car- 
 tilage which unites epiphysis 
 with diaphysis. The injury 
 is most common at the lower 
 ends of the humerus, radius, 
 and femur; it is seen also, but 
 more rarely, at the upper ends 
 of the humerus, femur, and 
 tibia, and at the lower end 
 of the tibia. The injury, 
 in all its aspects, so closely 
 resembles a fracture, as to 
 be considered by common 
 consent along with such in- 
 juries. 
 
 Mechanism. — Bones may 
 be broken in four different 
 w^ays: (1) by torsion; (2) by 
 flexion; (3) by distraction, and (4) by compression. For a bone to be 
 broken by torsion, it is necessary for one of its ends to be free, while 
 the other is fixed; the injury always is indirect, and the line of frac- 
 ture usually oblique. When a bone is broken by flexion, the force 
 may be either direct or indirect. All fractures by distraction are due 
 to indirect violence, and practically all produced by compression result 
 from direct violence. 
 
 Fig. 270. — Longitudinal (splitting) fracture of 
 tibia and fibula (involving knee-joint). Age, 
 forty years. Episcopal Hospital. 
 
CA USES 
 
 2'.»7 
 
 Causes of Fracture. Predisposing Causes. — Tlicsr arise citluT from 
 the (oiulitioii of the patient or that of the l)oiie afl'eeted. JJoiies of 
 the a(j('(l are more Hable to fracture, heeause more brittle, than those 
 of yoimg i)er.sons; but as tlie hitter lead more active lives, and are 
 more exposed to exciting causes, the number of fractures actually 
 occurriufj in the aj^ed is less than in the young. Likewise the male 
 .sv.r, from its greater ex])osure, is more lia})le to fracture than the 
 female. Certain r//,s7Y/.sT.s- of hones render them more liable to be 
 
 Fig. 271. — Transverse serrated fracture of 
 humerus. Episcopal Hospital. 
 
 Fig. 272. — Oblique and spiral frac- 
 ture of femur. Age three years. 
 Episcopal Hospital. 
 
 broken, especially osteopsathyrosis and malignant growths. The 
 situation of a bone may predispose it to fracture, the clavicle being 
 more often broken than the scapula, the lower than the upper jaw', 
 etc.; and the function of a bone has a predisposing influence, the bones 
 of the extremities being broken more often than those of the trunk. 
 
 Exciting Causes. — Fractures may occur at the point of impact, 
 from direct violence (gunshot, cart wheel, falling brick, etc.); or may 
 be due to transmitted force {indirect violence), as fracture of the 
 elbow from falls on the hand. 
 
298 FRACTURES 
 
 Fracture by mvscular action usually is a variety of fracture from 
 indirect violence, one end of a long bone being twisted violently 
 by the muscles attached to it, and being wrenched loose, as it were, 
 from the other end, which opposes its inertia to the sudden muscular 
 impulse; this is the explanation of fractures of the humeral shaft 
 from throwing a ball (Ashhurst, 1905). Muscular action may tear off 
 an apophysis (coracoid process, greater tuberosity of humerus, anterior 
 superior iliac spine, etc.), or may break the patella or olecranon by 
 sudden flexion over their neighboring condyles, as an over-bent lever. 
 
 S prain fractiire (Callender, 1870) is due to separation of a ligament 
 from its point of insertion, with detachment of a small shell of bone. 
 
 Spontaneous or Pathological Fractures are those due to preexisting 
 bone disease, where trauma is minimal, as in fragilitas ossium, 
 secondary carcinoma of bone, etc. 
 
 Symptoms of Fractures. — In addition to a history of injury, which 
 exists in all cases except some pathological fractures, there are both 
 symptoms and physical signs by which a diagnosis of fracture can be 
 made clinically, with very few exceptions; in such exceptional cases 
 the use of the or-ray nearly invariably will reveal the true nature of 
 the lesion. 
 
 Pain and Tenderness. — These are present in practically every case 
 and are by no means proportionate to the apparent degree of injury, 
 some very severe compound comminuted fractures causing the patient 
 less discomfort than a single subcutaneous break. When no other 
 physical signs are present, the surgeon should always suspect a fracture 
 when there exists persistent localized tenderness of a bone, following 
 injury; such a fracture may be subperiosteal or impacted, and the 
 surgeon should treat such a case as one of fracture until the incorrect- 
 ness of his diagnosis has been proved. 
 
 Swelling, Ecchymosis, etc., are present to some degree in nearly 
 all cases of fracture (Fig. 273), owing to coincident injury of the soft 
 parts; but they have no special significance. Abrasion over the seat of 
 fracture usually shows that the break is due to direct violence. 
 
 Deformity or Displacement. — This is one of the most constant and 
 valuable signs of fracture. It may be due either (1) to the fracturing 
 force, or may occur subsequently (2) from muscular action; both 
 these factors may be operative; or finally it may be caused simply 
 (3) by the weight of the limb. 
 
 1 . Deformity from the fracturing force is seen best in impacted and 
 in depressed fractures. In fractures with great displacement other 
 factors as well usually are at work. 
 
 2. Deformity from muscidar action is seen especially in the long 
 bones of the extremities, and occurs most markedly when the fracture 
 is close above or below the attachment of powerful muscles — as 
 above or below the insertion of the deltoid, below the insertion of 
 the iliopsoas tendon, above the origin of the gastrocnemius, etc. In 
 fractures of the patella and olecranon it is almost the only cause 
 of deformity. It is responsible both for the shortening, and for the 
 angular deformity, as well as for many cases of rotatory displacement. 
 
SYMPTOMS 
 
 299 
 
 Deforniity from nuiscular action is dopenflent in part on the natural 
 fcn<si<))t of the muscles, in j)art on inrolinitari/ conlractiou, (spasmodic) 
 from reflex nervous action, and in i)art on voluntary action. h\ the 
 patient. 
 
 1). DcJ'onnili/ from the force of (/rariti/ is seen in the outward rotation 
 of the leg whicii occurs in fractures of the fenuir; in the deformity 
 known as 'Moss of tiie carrying angle" in supracondylar fractures 
 of the humerus; in the dropping of the shoulder in fractures of the 
 clavicle, etc. 
 
 Fig. 273. — Ecchymosis twenty-four hours after fracture of surgical neck of humerus, 
 extravasation occurring in course of long tendon of biceps. Episcopal Hospital. 
 
 Direction of Disijlacement.— This may be longitudinal, lateral, 
 angular, or rotatory. 
 
 1. Longitudinal disylacement almost always consists in shortening: 
 lengthening is seen only in fractures of the olecranon and patella, and 
 in some of the calcaneum; in fracture of the lower end of the fibula, 
 lengthening of this bone may occur from inward rotation of the foot 
 (Malgaigne, 1841). If the fracture is transverse, there can be no 
 marked shortening unless there has first been lateral displacement, 
 as the amount of shortening which occurs in an impacted fracture 
 rarely exceeds one or two centimeters; oblique fractures, however, 
 permit of great shortening without much lateral displacement. If the 
 ends of the fragments are displaced so far as to pass by one another, 
 overlapping is said to exist, the more prominent fragment overruling 
 the less prominent. In fractures of the femur the shortening from 
 overlapping may be from five to ten centimeters (Fig. 274). In many 
 fractures it is requisite, and in most it is highly desirable, to take the 
 actual measurements of the sound and injured limb between known 
 
300 
 
 FRACTURES 
 
 fixed points to determine whether or not there is shortening, and not 
 to rely on the evidence of the eyes alone to determine this point. 
 
 2. Lateral or transverse displacement has been mentioned already; 
 it occurs mostly in transverse fractures, and when marked allows 
 overlapping. 
 
 Fig. 274. 
 
 -Fracture of fcnuir, fragments overlapping two inches. Plated. 
 Episcopal Hospital. 
 
 3. Angular deformity usually results from the fracturing force. This 
 is well seen in cases of green-stick fracture (Fig. 2()7); hut it may 
 be originally caused by muscular action, and usually is maintained 
 by this or by the force of gravity. 
 
 4. Rotatory displacement consists in the fragments being twisted on 
 their own axis in opposite directions, either from muscular action or 
 the force of gravity. In fractures of the radius above the insertion 
 of the pronator radii teres the upper fragment is supinated by the 
 biceps, while the lower is pronated by the pronator teres; in fractures 
 of the neck of the femur the lower fragment is rotated outward by 
 the force of gravity and the external rotator muscles, which are 
 more powerful than the internal rotators. 
 
uiAdNosjs :;(ii 
 
 DispUiri'iiiint iiuuj )i(d he due to fracture, but to some otlicr lesion. 
 DislociitioMs, old joint-diseases, exostoses, as well as other aU'ectioiis, 
 may cause deformity with shortening,', an^Milarity, or rotation; so 
 the surgeon must not place reliance upon deformity alone in the 
 diagnosis of fracture. 
 
 Mobility. -Preternatural mobility in a hone, following recent injury, 
 implying as it does motion at some point other than tlu; joints, is 
 almost j)athogn()monic of fracture; but the normal flexibility of some 
 bones (ribs, fibula, rachitic bones) should not be mistaken for abnormal 
 mobility. In some cases mobility is so great that it is evident at a 
 glance, the limb swinging flail-like at the site of fracture; in others, 
 especially where only one of two or more parallel bones is broken 
 (ribs, metacarpals, etc.), mobility may be difficult to detect. In 
 subperiosteal and impacted fractures it is entirely absent; and in 
 other forms of fracture it may be impossible to detect it owing to the 
 depth at which the bone lies, existence of swelling, etc. In fractures 
 close to a joint, and in those in which the line of fracture is wholly 
 or in part intra-articular, no mobility may be demonstrable. While in 
 a fracture a false point of motion exists, in a dislocation the mobility 
 of the affected joint is diminished. 
 
 Crepitus. — Crepitus is a term used to describe the grating sensation 
 appreciable by palpation and frequently also by auscultation (a 
 stethoscope may be used), when the ends of the fragments are moved 
 against each other. When present in connection with mobility, the 
 diagnosis may be considered estal)lished. Crepitus should not be 
 mistaken for the creaking of tenosynovitis, nor for the similar sound 
 produced by motion of some diseased joints; nor yet for the crackling 
 of subcutaneous emphysema. Crepitus may be absent, owing to 
 the ends of the fragments not being in contact (overlapping, separa- 
 tion), or to muscular or fibrous tissues intervening; in green-stick, 
 impacted, and subperiosteal fractures, there is no crepitus. 
 
 Loss of Function is another valuable sign of fracture, though it is 
 by no means universally present. Patients with fracture of the 
 fibula may continue at work, and apply for treatment only because 
 of deformity or persistent disability; the same is true of fractures 
 of the ribs; and of some fractures in which pain is absent owing to 
 nerve lesions, or in which it is not appreciated owing to the develop- 
 ment of mania a potu, etc. 
 
 Circumstantial Evidence of fracture, in addition to the above men- 
 tioned direct signs, is afforded by various occurrences: subcutaneous 
 emphysema corroborates a diagnosis of fracture of the nasal bones, 
 discharge of cerebrospinal fluid from the ear indicates a fracture of 
 the middle fossa of the skull, etc. 
 
 Diagnosis of Fracture. — If a surgeon conscientiously and system- 
 atically examines the patient there should be very few cases in which 
 the existence or non-existence of fracture remains doubtful. Inquiry 
 should be made as to the history of the accident, including the mode 
 of injury, the position of the patient, whether the lesion is due to a 
 
302 FRACTURES 
 
 fall of the patient, or to his being struck by another body. If he fell, 
 it should be ascertained, if possible, how he landed — whether on the 
 outstretched hand, whether his foot turned in or out, whether his 
 knee suddenly flexed or became hyperextended, whether his arm was 
 abducted or lay across the thorax, etc. Occasionally when a bone 
 breaks a crack is heard. 
 
 Inspection. — Inspection may show the patient supporting or pro- 
 tecting the injured part, may reveal evident deformity, shortening, 
 abrasion, swelling, etc. 
 
 Palpation. — Running the fingers lightly along the surface of the 
 suspected bone, the point of greatest tenderness, nearly always 
 corresponding to the site of fracttire, can soon be determined. Sup- 
 porting one end of the injured bone gently but firmly in each hand, 
 test is then made for abnormal mobility, by attempting to increase 
 or decrease angular deviation of the fragment, or to rotate one 
 fragment on the other. In fractures near joints, lateral mobility, 
 where none is normally present (elbow, knee) may thus be detected 
 (in dislocations there is immobility rather than aluiormal mobility). 
 In most cases crepitus will be elicited during the manoeu\Tes advised 
 for detection of mobility, but where overlapping exists it may be 
 necessary first to bring the fractured ends into apposition; when 
 crepitus once has been detected it is reprehensible to make attempts 
 at reproducing it merely for the edification of bystanders. 
 
 Mensuration. — ^Mensuration has been mentioned already as a 
 valuable means of detecting shortening. In the upper extremity 
 the fixed points employed are the tip of the acromion or the meta- 
 cromial tubercle, the condyles of the humerus, and the styloid pro- 
 cesses of the radius and ulna; in the lower extremity measurements 
 are made from the anterior superior iliac spine or symphysis pubis 
 to either of the malleoli; or to the lower border of the patella, head 
 of the fibula, etc. By placing the corresponding limbs in similar 
 attitudes and taking repeated and accm-ate measurements, the pres- 
 ence of shortening usually can be ascertained. It should not be 
 forgotten, however, that in many persons the two lower extremities 
 normally are not of equal length. 
 
 It is important to make a correct diagnosis and to institute proper 
 treatment as soon as possible after the injury is received; deformity 
 at first easily appreciable may soon be obscured by swelling, and 
 not only will the diagnosis then be more difficult than if made at 
 first, but reduction of the deformity and other proper treatment 
 will be less eflectual or even impossible if the case is not seen early. 
 In all cases, moreover, in which fracture is suspected, the case should 
 be treated as if fracture were present until the contrary is proved. 
 
 Skiagraphy. — Skiagraphy is a great aid in confirming a diagnosis 
 of fracture tentatively made, or in disproving its existence when 
 one is suspected. Whenever possible a skiagraph should be made 
 before the patient is examined, as a matter of record; and often it is 
 desirable for the surgeon to examine the plate before treatment is 
 
PROCESS OF UNION IN FUAC'TUHED BONES iJOo 
 
 instituted. (\Tt;iiiiIy after reduction has heen attenij)ted it is well 
 for him to have ocuhir e\idenee of what lie has accomplished; and 
 if reduction is not satisfactory he can try again. In making' radio- 
 graphs tlie fihn side of tlie phite is phaced next the patient's liml), 
 and the picture etched on the plate is the shadow of those parts 
 iniper\ious to the .r-rays. In looking at the develojx'd plate, if it 
 is held with the film side toward the observer, he is in the position 
 occuj)ied by the Crookes tube when the exposure was made, and, 
 therefore, is looking at the shadows of tlie bones from the side of 
 cxj)osure. In taking lateral views of the limbs, that bone or portion 
 of bone nearest the plate when the exposure was made, will be most 
 clearly defined. 
 
 Skiagraphs ojicn are very deceptive. For instance, if the bones overlap, 
 and lie in the same axis, a skiagraph which superposes one shadow 
 on the other may show no fracture; one which is taken in the same 
 plane as that in which angular displacement occurs, may show no 
 deformity. Hence it is a good rule always to have two plates 
 made, exposure being in planes at right angles to each other. If the 
 Crookes tube is too close to the limb its rays will be quite divergent 
 when impinging on the skiagraphic plate, and all the shadows will 
 be exaggerated; and the further a bone lies from the plate the more 
 rays it will intercept and the larger its shadow will appear. If the 
 Crookes tube is not accurately centred over the fracture, the shadows 
 cast by the fractured ends will be much distorted, perhaps markedly 
 exaggerating the deformity, amount of callus, etc. In passing judg- 
 ment upon a skiagraph, therefore, it is important to take these points 
 into consideration, and not to regard as evidence of malpractice 
 phenomena which may be quite easily explained in other ways. 
 
 Prognosis of Fracture. — Prognosis as to life is good. In large 
 series of statistics the general mortality from fractures is about 2.5 per 
 cent. Compound and complicated fractures have a higher mortality. 
 ^Multiple fractures, as I pointed out in 1907, in studying 240 cases, 
 give a mortality of about 25 per cent., even when deaths occurring 
 soon after the injury from hemorrhage, shock, visceral injuries, etc., 
 are excluded. In general it may be said that the chief causes of 
 death in fractures of any variety are visceral diseases (pneumonia, 
 uremia), delirium tremens, and, in the aged, exhaustion. 
 
 The prognosis as to the function of the fractured part depends 
 more upon treatment than any other single factor. As a rule, function 
 is more quickly and completely restored in children and young adults 
 than in the aged; and in those of sound constitution than those with 
 rheumatic or gouty tendencies. 
 
 Process of Union in Fractured Bones. — It has been entirely too 
 much the custom to regard bones as so many sticks or pieces of stone 
 embedded in the soft tissues. The student shoidd disabuse himself 
 of this idea, and should aim constantly to remember that bone is a 
 living tissue, composed of cells and intercellular substance, and dilTer- 
 ing chiefly in the composition of the latter from other tissues such as 
 
304 
 
 FRACTURES 
 
 muscle or epithelium. Bone reacts to injury or disease in very much 
 the same way as other tissues; the phenomena of inflammation and 
 repair may appear less active and slower than in the soft tissues, 
 but they are none the less present. A glacier is a fluid body, though 
 it looks solid; it flows slowly and invisibly, but none the less surely; 
 so with bone: processes measured by minutes or hours in soft struc- 
 tures may take days or weeks in bone, but they are the same in kind. 
 When a bone is broken, the surrounding soft parts are more or less 
 damaged, and themselves react to the injury by the process of inflam- 
 mation as described in Chapter I. 
 A certain amount of blood is extrav- 
 asated between the ends of the 
 broken bone, and the various cellular 
 elements of the tissues in the injured . 
 area (bone cells from the marrow and 
 periosteum, muscle cells, connective 
 tissue cells, leukocytes, etc.), prolif- 
 erate, and aid in removing debris and 
 causing organization in the mass of 
 inflammatory lymph which is formed. 
 The intercellular substance of the 
 bone is temporarily absorbed or re- 
 moved from the fractured ends by 
 osteoclasts, and the exudate forming 
 between the fragments, which is 
 known as callus, is strictly analogous 
 to the inflammatory lymph which 
 surrounds it and with which it is 
 continuous. The ends of the frag- 
 ments thus become soft and sticky, 
 and may be compared to the ends 
 (if a broken stick of sealing wax 
 which one seeks to weld together 
 JBM' again after heating in a flame. This 
 
 ^^BHBm callus is derived largely from the 
 
 ^^^^^^HF ^ medulla of bone, by proliferation of 
 
 ^ I osteoblasts. This portion of it is 
 
 known as interior or pin-callus, while 
 that portion formed from the perios- 
 teum is known as ensheathing or ring- 
 callus; the material lying between 
 the ends of the compact substance of the bone is known as the 
 yermanent or definitive callus as distinguished from the pin and ring 
 callus, which is called provisional or temporary callus. 
 
 In the course of ten days or two weeks the callus becomes impreg- 
 nated with lime salts, that derived from periosteum often passing 
 through a cartilaginous stage; and the bone can no longer be freely 
 bent at the seat of union (Fig. 27o). The callus gradually becomes 
 
 Fig. 27.5. — • Skiagraph showing 
 callus several weeks after fracture of 
 radius. Episcopal Hospital. 
 
PROCESS OF UNION IN FRACTURED BONES 'M)5 
 
 condensed as organization proceeds and remains only as a sliglit 
 thickening at the site of previous fracture; but the pin callus usually 
 is not entirely absorbed, and complete restoration of the medullary 
 canal is rare If there has been exuberant outpouring of callus (Fig. 
 27()). it may cause union between adjoining bones, may interfere with 
 full Hexion or extension of a joint, may limit rotation in the forearm, 
 may grow around nerves or tendons, or cause injurious pressure on 
 them or on vascular channels, resulting in trophic changes, edema, etc. 
 
 Fig. 276. — Skiagraph of exuberant callus from fractures of elbow and forearm. 
 
 If the fracture is subperiosteal the amount of ring-callus formed 
 will be inappreciable; and the less the primary displacement and 
 the more accurate the reduction of the fractured ends, the less will 
 be the amount of the ring-callus. In fractures of the skull or ribs, 
 and in impacted fractures, where displacement is slight, no appreci- 
 able callus is formed. If the periosteum is stripped up from the shaft 
 of a bone blood-clot will form beneath it, as well as between the 
 broken ends, and becoming organized will cause thickening of the 
 shaft, as the periosteum will be unable to fall back into its normal 
 position (Fig. 277). The periosteum is rarely completely detached 
 from the broken ends, usually remaining at least on one side as a 
 periosteal bridge (Oilier, 1867), which may secure firm bony union 
 even in cases where marked displacement persists. 
 
 The process described above usually does not make its beginning 
 manifest for several days after the occurrence of fracture, and is 
 longer delayed in comminuted and in compound than in simple 
 20 
 
306 FRACTURES 
 
 fractures. In multiple fractures it is a very usual thing for one or 
 two fractures to unite in the ordinary time, and for the other fractures 
 to remain ununited until those first uniting are quite firm, when 
 union may commence in the remaining fractures. In simple fractures 
 fairly firm union is present at the end of two weeks, though at this 
 time, and in larger bones for some weeks afterward, bending at the 
 seat of fracture still may occur. An adult's femur requires usually 
 eight or ten weeks for absolutely firm union to occur. It is said that 
 in no fracture is the structure of the bone entirely restored until a 
 year after the accident. 
 
 Fig. 277. — Skiagraph of supracondylar fracture of humerus, showing new-formed bone 
 beneath bridge of periosteum, three weeks after injury. Episcopal Hospital. 
 
 Delayed union is a relati^'e term, since no fixed limits can be set 
 within which union should be firm. If union has not occurred at the 
 end of ten or twelve weeks, it is usual to regard the case as one of 
 Non-union or Ununited Fracture. In these cases the tissue between 
 the fragments remains in a fibrous condition, no bone salts being 
 deposited. 
 
 Treatment of Fractures. — The general principles already- inculcated 
 as proper in the treatment of inflammation guide the surgeon in "the 
 treatment of fractures. The indications are to replace the broken 
 bones in proper position, with due regard for the condition of the soft 
 
TREATMENT OF SlMl'LE FRACTURES 
 
 .)()/ 
 
 parts, to ni((inf(tin ihe fraqntcid.s in proper position, and to drcKs the 
 injured part at stiilahle interrals until cure is complete. 
 
 Treatment of Simple Fractures. — Fractures often are received at 
 a distance from the patient's home or a surge(m, and it becomes 
 necessary to transi)ort the ])atient to a place where the injury can 
 he treated. The fractured lind) should be rendered as innnobile as 
 possible; this may be accomi)lislied by the temporary application 
 of any aNailable support (shingles, canes, umbrella ribs, bark of 
 trees, twigs, etc.), ai)plied o\er the clothing or suita})Ie padding, or 
 even by wra})i)ing the limb firmly in clothing, without constriction; 
 if the patient is unable to walk, he is carried on a shutter or on a 
 stretcher improvised from poles and clothing, to his home or the 
 nearest hospital. 
 
 Fiu. 27s. — Showing fragments of 
 brokon bone in contact "end-on," and 
 with not too much lateral displacement 
 for firm union. 
 
 Fig. 279. — Fragments displaced later- 
 ally and with angular deformity; contact 
 not sufficient for firm union. 
 
 1. Reducing the Fracture. This, which often is expressed by the 
 term ".setting the bone," is a relative term, since comparatively 
 few broken bones can be accurately restored to their original form; 
 and in the case of shafts of long bones it is not always necessary 
 that reduction should be accurate. Nevertheless, the aim must be to 
 secure as accurate reduction as possible, and in the case of fractures 
 near joints (especially the elbow and ankle) it is extremely important 
 to do so; but in the middle of the shaft of a long bone it is sufficient 
 to secure firm bony union, wath no appreciable shortening, with preser- 
 vation of the normal axis of the limb, and without rotation of one frag- 
 ment on the other. For the first and second results to be obtained 
 it is necessary for the fragments to be in contact "end-on," not only 
 
308 FRACTURES 
 
 by lateral contact; and for the lateral displacement not to exceed 
 two-thirds of the diameter of the bone (Figs. 27S and 279). The axis 
 of the limb sometimes may be preserved without end-to-end contact 
 of the fragments, but it is very rare for firm union to be secured 
 (except in children), and shortening never will be absent unless 
 end-to-end contact is obtained. 
 
 The methods of securing reduction are many, and will be described 
 when the injuries of the individual bones are discussed. It is sufficient 
 to point out here that other than manual force seldom is necessary, 
 if the surgeon takes advantage of the relaxation of the muscles which 
 may be secured by position of the limb; rarely will anesthesia be 
 necessary, and still less often operative intervention (p. 130). Secur- 
 ing muscular relaxation by position, the surgeon with his hands 
 makes extension and counter-extension on the broken bone, and, 
 by gently but firmly a})plied direct pressure, pushes the ends of the 
 fragments into contact: if reduction has been properly secured, 
 there will be distinct crepitus as the broken ends come together, 
 the normal length of the 1 mb will be restored, and bony deformity 
 will disappear. It then becomes necessary merely to maintain reduc- 
 tion until union is sufficiently firm. 
 
 2. Maintaining the Fragments in Apposition. For this purpose it 
 is usual to employ splints or other external support, held in place 
 by bandages, plasters, etc. Splints are made of various materials 
 (wood, tin, wire, gypsum, etc.), and of various special forms. These 
 will be described when discussing fractures of the several bones. 
 It is above all things important to recognize the fact that splints 
 are not used for the purpose of overcoming deformity, but merely 
 to maintain the limb in correct position after the deformity has been 
 reduced. The action of splints in this regard may be much assisted 
 by the position in which t'he limb is dressed, and by the use of iveighi 
 extension to overcome spasmodic muscular contraction. If a fracture 
 is close to a joint it is necessary to immobilize the joint also; in 
 general terms, it is desirable to immobilize so much of the limb as 
 will prevent any lever action being transmitted to the site of fracture 
 by movement of the portions of the limb left free. 
 
 Before a splint is applied it should be covered snioothly with raw 
 cotton, oakum, or some similar material in sufficient amount to pre- 
 vent painful pressure on the limb, special care being taken to protect 
 bony prominences, superficial nerves, bloodvessels, etc. It often is 
 well to apply between the splint and its padding, and over the ends 
 of the fragments, pads suitable to prevent recurrence of deformity, 
 provided no pressure is exercised which might injure the soft parts. 
 An excellent rule is never to apply a bandage beneath the splints around 
 the fractured region: in all fractures there is more or less injury of 
 the soft parts, and the reactive swelling which occurs in these has 
 demonstrated on numerous occasions the danger to which the patient 
 is subjected by neglect to observe this rule; a bandage which seems 
 loose enough when first applied may in a very few hours become so 
 
TREATMENT OF SIMPLE FRACTURES 309 
 
 tij^lit as to f'aus(> serious constriction, pcrliaps rcsnltinj^ in <i;a!ifi;rcne 
 of the extremity. Under all circnnistances it is well to lca\-e exposed 
 the tips of the fingers or toes, and to direct the nurse or the nienihers 
 of the patient's family to examine their condition at frequent intervals; 
 should any interference with the circulation l)ecome evident the dress- 
 ings must be removed at once and be re-aj)])lied more circumsi)ectly. 
 
 At the first visit, the surgeon should proceed to examine the injured 
 member as described at p. 301; but he should not attempt to reduce 
 the fracture until he has all his dressings prepared for application. 
 
 3. The after-care of a fractured bone involves removal of the 
 (Iressing frequently enough to make sure that the soft parts are in 
 good condition, and that reduction is maintained by the dressing 
 employed. The surgeon never should neglect to see the patient on 
 the day after the dressing is first applied, and to ascertain for him- 
 self that the limb is in good condition, and that the dressing is com- 
 fortable; an imcomfortahle dressing always is inefficient even if not 
 positively harmfid; but if the dressing is comfortable it is not desirable 
 to re-dress the limb more than two or three times weekly at first, 
 and less often as union progresses. As the splints and bandages 
 are being removed for re-dressing, the surgeon should support the 
 fractured part in such a way as to substitute his support for the 
 splints, preventing dislocation of the fragments, and rendering dress- 
 ing of the fracture entirely painless. While this support is main- 
 tained, the patient's skin should be sponged oflf gently with dilute 
 alcohol, employing such gentle friction as will stimulate the circula- 
 tion. I do not approve of massage or mobilization in the treatment 
 of fractures, except in so far as they are unavoidable in procuring 
 proper care of the soft parts; and while I acknowledge the truth of 
 the dictum (Lucas-Championniere, 1910) that "a certain amount of 
 motion between the fragments encourages the formation of callus," 
 I am firmly of the opinion that even the most careful immobilization 
 by splints allows, and proper care of the soft parts, as above indicated, 
 provides that "certain amount" of motion which is desirable, and that 
 any surgeon who attempts more, in the vain idea that he is following 
 modern teaching, will succeed either in stirring up such an amount 
 of callus (especially in children) as to cause deformity and injurious 
 pressure on the soft parts, or will (in most adults) leave his patient 
 with an imunited fracture. When the ends of the bones become 
 "stick}^," and no tendency to displacement exists, the surgeon may 
 then begin at each dressing to make very limited degrees of passive 
 motion in the neighboring joints, meanwdiile maintaining support 
 at the seat of fracture. Under no circumstances should the passive 
 motion cause pain. When union is firm enough for all external 
 support to be discontinued, function usually will be more comfort- 
 ably and quickly recovered by active movements by the patient 
 himself, than by further attempts at passive motion; and if a fracture 
 has been treated properly in the first place, massage rarely will be 
 necessary to accelerate the cure. 
 
mo FRACTURES 
 
 Operative Treatment of Simple Fractures. — Tliere are only two 
 indications for the "open method " of treating simple fractures, 
 so strenuously advocated by Lane (1905) and other surgeons: (1) 
 If the fracture cannot be reduced properly without operation. (2) If 
 proper reduction cannot be maintained without direct fixation of 
 the fragments. 
 
 1. When Proper lieduciion is hnpussihle. — Impossibility is here 
 a relative term, since what is impossible for one surgeon may not 
 be so for another; and I use the qualification "proper" reduction, 
 because I do not wish to imply that operation is indicated whenever 
 accurate, exact, perfect anatomical replacement is impossible, but 
 only when such degree of reduction as is described at p. 307, as 
 requisite for proper function, cannot be secured without open opera- 
 tion. The chief causes of irreducibility are muscular spasm (usually 
 this can be overcome by general anesthesia, weight extension, or 
 sometimes by tenotomy), interposition of muscle, fascia, etc., between 
 the fragments (sometimes this can be overcome by manipulation 
 under an anesthetic), buttonholing of one fragment in the deep 
 fascia, joint-capsule, etc. (this usually requires incision), complete 
 rotation of a detached fragment (apophysis, condyle, etc.), and /;//- 
 paction of the fragments (if desirable, which is not always the case, 
 this usually may be overcome by manipulation with or without 
 an anesthetic.) 
 
 2. When SuhscquctU Displacement Cannot he Prevented. — This also 
 is a relative condition, depending upon the skill of the surgeon in 
 devising and applying efficient retentive apparatus, and upon the 
 extent to which displacement occurs. In the aged or feeble it may 
 be wiser to permit recovery with considerable deformity than to 
 undertake an inexpedient operation. Uncontrollable displacement 
 generally is due to the nature of the fracture itself (marked obliquity, 
 much comminution, etc.), to muscidar action, or to the refractory 
 conduct of the patient. 
 
 Apart from fractures of the patella, which are conceded to require 
 operation (because of irreducibility) unless positive contraindications 
 exist, the two forms of injury in which operation is most often urged, 
 are fractures of both bones of the forearm, and those of the femur; 
 so far as I am aware, however, it has yet to be shown that operative 
 methods in these instances can be safely applied by the average 
 surgeon, or that he can secure by uniform resort to operation as 
 satisfactory results in as large series of consecutive cases as have 
 been obtained by conservative treatment. 
 
 If operation is decided upon, it is best done either on the day of 
 injury or not until about the end of the first week, or early in the 
 second week after the injury, since at this time the primary swelling, 
 etc., will have subsided, and any callus that may have formed still 
 will be soft and easily removed; moreover, infection is less likely 
 to follow than if early operation is attempted. The operation, u'hich 
 should be strictly aseptic, consists in exposing the fracture through the 
 
OPERATIVE TUKATMKNT OF HlMl'LE FRACTURES :U 1 
 
 pr«iH'r muscular inU'rsi)a(r, excising exuberant callus, reiuovuig 
 interposed soft tissues, and in securing reduction (which is not always 
 easy) if possible without resection of bone. Then if very slight 
 tendency to dislocation of the fragments exists it is not necessary 
 to use mechanical means to hold the ends in apposition, ])rovided 
 the surgeon feels capable of maintaining reduction by his external 
 dressings. If there is still a tendenc>' to displacement, the fragments 
 (in the case of small bones) should be sutured with heavy cliromic 
 catgut, which will not be absorbed until union is so firm as to prevent 
 sul)seqiient displacement; in the case of the femur and in oblique 
 fracture of the til)ia it is safer to use a metal plate, since maintenance 
 
 Fig. 280.— Hamilton's drill. 
 
 Fig. 281. — Fragments united by two wire 
 sutures, inserted in different planes. 
 
 of reduction bv external dressings alone usually is difficult. The 
 form of plates \ised by Lane (1905) probably is best: these are of 
 steel, of various sizes, and are applied to the bone without displacmg 
 the periosteum. About three screws are inserted in each fragment ; the 
 holes are bored by a suitable drill (Fig. 280) or dental engine, should 
 extend into the medulla and should be slightly less in diameter than 
 the screws; the screws should have round heads, should have the 
 tliread carried up to their heads and should be just long enough to 
 enter the medullary cavity. The use of plates has almost super- 
 seded wire sutures "in large bones (femur, tibia, humerus, lower half 
 of radius), but in smaller bones (clavicle, ulna, fibula) wire sutures 
 are efficient and may be more easily applied; it is best to use two 
 
312 FRACTURES 
 
 sutures, at right angles to each other (Fig. 2<S1). Silver wire is much 
 used, but it is decidedly inferior to aluminum or phosphor bronze 
 wire, which is much more pliable and stronger. If all oozing has 
 been controlled by ligature or suture, the wound may be closed Avith- 
 out drainage, but in case of doubt it is better to leave a rubber tube 
 in the wound, for twenty-four to forty-eight hours. 
 
 After such an operation the process of union is apt to be delayed, 
 and in a fair proportion of cases operated on by the average surgeon 
 a mild degree of infection occurs, and only fibrous union results. If 
 the operative treatment of simple fractures were confined, as it 
 should be, to skilful surgeons with all the facilities afforded by the 
 best modern hospitals, no doubt better results would be obtained. 
 
 Treatment of Complicated Fractures. — Rvpture of the main artery or 
 vein of a limb complicating a fracture of the part requires the same 
 treatment as when no fracture is present (p. 233) ; if gangrene follows 
 amputation should be done at the site of rupture; but if the axillary 
 artery is ruptured in a case of fracture of the upper part of the humerus, 
 it usually is sufficient to amputate tlirough the seat of fracture; and 
 if the popliteal artery is ruptured, to amputate at the knee-joint if 
 the fracture is below the knee, and tlirough the seat of fracture if 
 this is in the femur. Injuries of nerves require immediate suture, 
 if it is evident that function is completely destroyed; otherwise oper- 
 ation should be delayed until after consolidation of the fracture, 
 since recovery from contusion may be nearly complete. A severe 
 rcound of the soft parts usually takes precedence over the fracture, 
 and must be treated suitably irrespective of the latter; if sufficient 
 to render certain the occurrence of gangrene, amputate at the point 
 of injury to the soft parts. Dislocation of the neighboring joint, 
 most often encountered at the shoulder, usually requires incision 
 and direct replacement of the luxated fragment; though sometimes 
 it is possible to secure reduction by manipulation after putting up 
 the fracture in splints; operation is best postponed until seven or 
 eight days after the injury. 
 
 Treatment of Compound Fractures. — If the limb is so severely 
 injured that gangrene is sure to occur, or if it would prove useless 
 even if it could be saved, it is best to amputate at once; the site of 
 section of the bones in such cases is determined by the condition 
 of the soft parts available for making flaps. 
 
 A fracture which is made compound merely by the protrusion 
 of the bones tlirough the soft parts is much less dangerous than 
 one in which the soft parts have been crushed or pulpefied by the 
 same force which produced the fracture; because in the latter case 
 there is much greater devitalization of tissue, infection is carried 
 deeply into the soft parts, and comminution of the bones is the rule. 
 
 A compound fracture in itself requiring amputation, and compli- 
 cated by a simple fracture higher in the same limb, usually will 
 require amputation at the highest point of injury. 
 
 A compound fracture involving a joint sometimes requires ampu- 
 
TREATMENT OF COMI'OUND FRACTURES 313 
 
 tat ion falniost always at the knee), hut conservative treatment 
 with strict antiseptic methods often will secure a useful limh e\'en 
 if motion is limited. 
 
 If it appears in any way likely that a useful Hmh can he saved, 
 especially in the upper extremity, the surgeon must undertake repair 
 of the soft parts and reduction of the fragments with antiseptic 
 methods as detailed at p. H)7. Jn almost every case the jjatient should 
 be anesthetized, and the priiJiary dressing made to assume the character 
 of a formal operation. If the ends of the bones project through 
 the soft parts, they should not be reduced until after the entire 
 wounded area has been surgically cleansed. The wound in the soft 
 parts frequently has to be enlarged, to permit of reduction and repair 
 of the deeper tissues (Fig. 282). It seldom is necessary to resect the 
 ends of the bones, reduction usually being possible by relaxing the 
 nuiscles by the position of the limb, and bending the bones at an 
 angle until their ends meet, then using the apposed fragments as a 
 fulcrum on which to straighten the limb out again. 
 
 Fig. 282. — Compound fracture of humerus, bone protruding. Photographed 
 just before operation. (See Fig. 283.) Episcopal Hospital. 
 
 Where the bones are much comminuted, such fragments as are 
 entirely detached should be removed, while those that are partly 
 adherent should be replaced, in the hope that they will aid in pro- 
 curing union. Often the soft parts are stripped so widely from the 
 bones that it is impossible to prevent recurrence of displacement 
 even when reduction is easy. Under these circumstances the bones 
 may be fixed by some form of internal splint as described in connection 
 with ununited fracture (Fig. 283); usually it is better not to plate 
 a recent compound fracture (since bony union seldom follows such a 
 course), but to postpone the plating until the soft parts have healed and 
 asepsis can be assured. Particular attention should be paid to suture 
 of nerves, muscles, and tendons. The wound, unless very slight, 
 should be drained for about forty-eight hours; by arranging the 
 dressings as described at p. 166, the drainage tube may be removed 
 without disturbing the fracture. In the lower extremity, a gypsum 
 splint, trapped over the seat of injury, makes a very good appliance 
 for the treatment of compound fractures; but in the upper extremity 
 ordinary splints used in cases of simple fracture are quite satisfactory-. 
 
314 
 
 PiiACTUREH 
 
 Frequently irrigation (p. 1()8) must be employed for several clays 
 to ensure vitality of the limb; and the frequency of dressings must 
 be determined l)y the condition of the soft parts. Union is much 
 
 Fig 283— Silver plate on compound fracture of humerus. (See Figs. 282 and 284.) 
 
 Episcopal Hospital. 
 
 more delayed than in simple fractures; and though fibrous union 
 often is the best that can be secured, it may furnish the patient with 
 a useful limb (Fig. 284). 
 
TREATMENT OF HADLY UNIT El) ERACTUliES 
 
 .Slf) 
 
 Treatment of Badly United Fractures. — It" the case is seen before 
 firm union has occnrred, the jxjsition usually may he imi)roved by 
 
 Fig. 2S4. — Fibrous union following pltited compound fracture of left humerus. 
 (See Figs. 282 and 283.) Episcoi)al Hospital. 
 
 ju(Hfious application of pads under the splints, or even by refractur- 
 ing the bones manually and dressing them in the improved position. 
 The question whether impacted 
 fractures should be reduced is 
 discussed under the lesions of 
 the various bones. If the case 
 is seen first after bony union 
 has occurred, it is not always 
 advisable to attempt reduction 
 of the deformity if function is 
 good, since non-union may result, 
 or, even if firm union is secured, 
 loss of function may accompany 
 it. SJwrtcning, as such, unless 
 due to angular deformity, scarcely 
 ever can be remedied; indeed, 
 to secure end-to-end apposition 
 of the fragments it often is 
 necessary to resect their ends, 
 thus increasing shortening; and 
 attempts to lengthen a bone by 
 oblique division usually are nulli- 
 fied by contractions in the sur- 
 rounding soft parts. On these 
 accounts, operative measures 
 are directed toward overcoming 
 lateral displacement, rotatory and 
 angular deformity, or to the re- 
 moval of exuberant callus. 
 
 Careful skiagraphic studies pm. 285.— vicious union following frac- 
 
 should be made of the fractured ture of forearm: angular deformity and loss 
 
 , ^ , of rotation. Suitable for operation. Epis- 
 
 region, so that the surgeon may copal Hospital. 
 
316 
 
 FRACTURES 
 
 plan his method of operation in advance. In some cases simple 
 refrachire, by the hands or osteoclast (p. 420), will be sufficient; in 
 others (Fig. 285) it is necessary to cut down on the fragments and resect, 
 treating the case then as one of ununited fracture (p. 31 S); while in 
 still others, linear or cuneiform osieoioiny will give the best results. 
 
 Fig. 286. — Deformity from irreducible separation of lower radial epiphysis. 
 (See Fig. 287.) Episcopal Hospital. 
 
 In deformity from a separated epiphysis it is better usually to divide 
 the diaphysis close to the epiphyseal line, and not to inflict further 
 damage on the immediate site of injury, for fear of interfering with 
 subsequent growth (Figs. 286 and 287). 
 
 Fig. 287. 
 
 -Osteotomy of radius to correct deformity shown in Fij^ 
 Episcopal Hospital. 
 
 286. 
 
 Ununited Fractures. — The distinction between delai/cd union and 
 vnunited fracture, as was pointed out at p. 306, is difficult to draw; 
 save that in the former condition union frequently occurs under 
 conservative treatment, while in ununited fracture it rarely does. 
 The most marked degree of non-union, constituting pseudartJirosis, 
 is that in which a bursa forms between the ends of the fragments, 
 there being almost a flail-like joint present (Fig. 288).- In ordinary 
 cases there is rather dense fibrous tissue between the ends of the 
 bones, which are pointed and atrophic; and while this may prevent 
 lateral displacement of the fragments, it allows angulation at the 
 seat of fracture. 
 
 Causes. — The chief causes of non-union in fractures are: (1) Failure 
 to secure end-to-end apposition of fragments. (2) Comminution of 
 the fragments, especially in compound fractures. (3) Imperfect 
 immobilization soon after the accident. (4) Interposition of soft 
 tissues. (5) Constitutional condition of the patient, rendering his 
 
UNUNITED FRACTURES 
 
 317 
 
 processes of repair ineft'ectiial. These factors, several of which may 
 co-exist, are mentioned in what I l)eHeve is their order of frequency, 
 with the possible excej)tion of the j)atient's constitutional condition, 
 which in many cases undoubtedly is the chief cause of non-union. 
 But it should be noted that interposition of soft tissues, though 
 comparatively infreciuent, always results in non-union when present. 
 
 Diagnosis. — The diagnosis rarely presents difhculties, if the seat of 
 injury is carefully and repeatedly examined; it is a truism to state 
 that the firmer the union the more difficult it is to detect motion. 
 A skiagraj)li may aid, since it will show absence of bony structure 
 between the fragments. 
 
 Treatment. — The treatment depends upon whether the patient is 
 seen during the stage of delayed union, or whether he first comes 
 
 imder the surgeon's observation when non- 
 union has existed for months or years. The 
 surgeon should endeavor to ascertain the 
 cause of the condition, and should attend 
 to the patient's general health, administering 
 cod liver oil, phosphates, thyroid extract, 
 etc. If separation of fragments can be 
 excluded, conservative measures should be 
 tried first In the case of delayed union, 
 the first thing to do is to try what strict 
 immobilization for a period of four to six 
 weeks will accomplish: this frequently secures 
 firm union; but if it fails, trial should be 
 made of functional use of the part, with 
 the fracture supported in splints, braces. 
 
 Fig. 28S. — Pscudar- 
 throsis of humerus with 
 ankylosis of elbow, follow- 
 ing compound comminu- 
 ted fracture. Not suita- 
 ble for operation. Epis- 
 copal Hospital. 
 
 Fig. 2S9. — Moulded binder's-board splint, for delayed 
 union after fracture of both bones of forearm. Epis- 
 copal Hospital. 
 
 etc. ; and of rather vigorous massage of the affected limb. A fracture 
 of the leg bones with delayed union frequently will grow firm when 
 the patient begins to walk around in his gypsum ca.se; for delayed 
 union of the femur a well fitting walking brace is more efficient; 
 while for the humerus or forearm a light splint of binder's-board 
 to support the seat of fracture will allow free use of the hand and 
 
318 
 
 FRACTURES 
 
 elbow. The patient (Fig. 289), a skiagraph of whose forearm is shown 
 in Fig. 347, eured his own delayed union by returning to his black- 
 smithing work, securing perfect functional use in spite of the bony 
 deformity, which, howe^'er, was not appreciable through the thick 
 mass of muscles. 
 
 Should this degree of stimulation fail to develop osseous union, 
 the patient may be anesthetized, and the ends of the bones vigorously 
 rubbed together, and then immobilized for a few weeks; this pro- 
 cedure often arouses osteogenetic processes and secures firm union 
 when milder methods are ineffectual. Bier (1905) advocates stimula- 
 tion of osteogenesis by injecting around the ends of the fragments 
 30 to 40 c.c. of venous blood freshly drawn from the patient. 
 
 If conservative measures fail, the question of operation rises; 
 but in every case the surgeon should stop to consider whether any 
 operation is apt to improve matters, or whether the patient has not 
 
 a sufficiently useful limb as it is. The 
 mere doing of an operation does not 
 ensure the occurrence of bony union; it 
 may leave the patient with non-union, 
 and with increased shortening, since 
 resection of the fragments usually is 
 necessary. But where deformity can 
 be decreased, and disability lessened, 
 operation is indicated. 
 
 Operation. — The fracture is exposed 
 through the proper muscular interspaccj 
 exuberant callus is removed with gouge, 
 chisel, and Volkmann's sharp spoon, and 
 the ends of the fragments are freshened 
 with the saw, the least possible amount 
 of bone being removed which exposes 
 healthy osseous structure and allows 
 proper apposition. In some cases simple 
 end-to-end approximation is sufficient; 
 in others a form of mortise and tenon 
 joint is preferable (Fig. 290). In either 
 case it is desirable to fix the fragments, 
 and undoubtedly the best way to secure 
 this and to encourage osteogenesis is by use of a bone transplant, 
 taken from the crest of the patient's tibia (p. 504). The trans- 
 plant may be set in the medullary cavity (intramedullary splint), 
 or, which is easier, a slot may be cut in each fragment, and the trans- 
 plant implanted laterally as a bridge. In the hip (ununited fracture 
 of the cervix) I have secured a well-nigh perfect result by driving a 
 bone peg through the fragments (Fig. 291). The use of such trans- 
 plants is fast superseding the employment of steel plates and wire in 
 operations for ununited fracture. The strictest aseptic technique is 
 requisite to secure satisfactory results. 
 
 
 Fig. 290. — A form of mortise 
 and tenon joint useful in opera- 
 tions for ununited fracture. 
 
SI'ECIA L FR ACT IRES 
 
 319 
 
 The wound slioiild not \)v (iraiiicd, if strict licinostasis has been 
 secured before ch)sing it, i)Ut in doubtful cases it is safer to 
 leave a tube in place for thirty-six to forty-eif,dit liours. If a sinus 
 persists after recovery, as sometimes is the case when the plate 
 or wire suture has been used, the foreign body should l)e removed, 
 otluTwise it may be allowed to remain indefinitely. Dr. Edward 
 Martin has recently removed a silver plate inserted by my father, 
 which only at the expiration of seventeen years began to work loose 
 and produced a simis. 
 
 Fig. 291. — Ununited fracturo of the neck of the femur treated V^v l)one transplan- 
 tation. Bony union; no shortening; free motion, f^jii.scopal Hospital. 
 
 SPECIAL FRACTURES. 
 
 The general subject of fractures and their treatment has been 
 so fully discussed in the preceding pages, and so many excellent 
 monographs on the subject are readily obtainable, that in speaking 
 of the injuries of the several bones I shall be as brief as possible. 
 As fractures of the skull and of the spine are of interest chiefly in 
 connection with injuries to their contained structures, their con- 
 sideration is postponed to Chapter XVI and XVII respectively. 
 
320 
 
 FRACTURES 
 
 FRACTURES OF THE FACE BONES. 
 
 Injuries of the face bones are due almost without exception to 
 direct violence; edema and ecchymosis often are marked, owing 
 to the abinidance of loose cellular tissue overlying the bones, and 
 hemorrhage into the nasal or oral cavities is quite frequent, the 
 fractures being compound on the mucous surface. Antiseptic sprays, 
 mouth washes, etc., are indicated under such circumstances. Union 
 occurs rapidly. 
 
 Fiu. 292, — Fracture of nose, ciiihtecn hours 
 after injury. Episcopal Hospital. 
 
 Fig. 293. — Fracture of risht malar 
 bone, from pressure by elbow in playing 
 basket ball. Episcopal Hospital. 
 
 Nasal Bones. — These may be crushed directly inward, or as is 
 more often the case, may suffer lateral deviation. The epistaxis fol- 
 lowing the injury usually subsides in a few minutes. The deformity is 
 characteristic, and the diagnosis usually is made by inspection (Fig. 
 292), and is confirmed by crepitus as the displacement is corrected. 
 This often may be accomplished by external pressure, but in some 
 cases is more effectually secured by leverage from within by a bone 
 elevator. There is no marked tendency for recurrence of deformity, 
 and retentive appliances generally are useless save to protect the 
 part from injury. A strip of adhesive plaster may be carried 
 across both cheeks and the bridge of the nose, as a precaution. As 
 swelling subsides, deformity may appear more evident, and often it 
 is desirable to mould the nose into shape by pressure every day or so 
 during the first week. Rarely can complete symmetry be restored. 
 Union is firm in ten days or two weeks. 
 
 Malar Bone. — This is rarely fractured. Usually there is depression, 
 (Fig. 293) which is best overcome by early incision under an anesthetic 
 and direct elevation of the fragment. Fractures of the zygoma often 
 are comminuted, and require the same treatment. 
 
FRACTURES OF THE FACE BONES 
 
 321 
 
 Maxilla. Fractures of this bone are not frequent, but sometimes 
 occur with luuhipk" fractures of tlie face. They are often compound 
 into tlie nose or moutli. Asynunetry of the alveolar process is the 
 main diaf;;nostic point. Impaction is usual, and must be reduced 
 to restore symmetry. If maintenance of reduction proves difficult, it 
 is well to liave a special splint constructed l)y a competent dentist 
 (Aller, 1914). 
 
 Mandible.— Fracture of the lower jaw is the most important, and, 
 with excei)tion of the nasal bones, probably the most frequent of 
 those of the face. It is due frequently to a blow from the fist, some- 
 times to the kick of a horse, to sudden jerkinj? upward of a mule's 
 head, or to a fall. Fracture involves either the body of the bone, 
 the condyle, or the coronoid j^rocess. 
 
 Fig. 29-4. — Skiagraph of fracture of mandible in front of angle. Age twenty- 
 seven j-ears. Episcopal Hospital. 
 
 Fracture of the body of the mandible occurs either near the symphysis, 
 or, most often, anterior to the insertion of the masseter muscle. A 
 rare fracture is detachment of the mental eminence, carryiiig the 
 genial tubercles, and (by relaxation of the geniohyoid and geniohyo- 
 glossus muscles) permitting the tongue to fall backward, perhaps 
 suffocating the patient; this fracture requires immediate operation 
 with suture of the fragment (G. G. Davis, 1894). A similar condition 
 may exist in a double fracture of the jaw, on each side of the symphysis. 
 Fracture in front of the masseter muscle, or posterior to the mental 
 21 
 
322 FRACTURES 
 
 foramen, is the most fre()ueiit injury: tlie line of fracture usually 
 is bevelled, permitting separation of the fragments as the posterior 
 is drawn toward the middle line by the mylo-hyoid and internal 
 pterygoid muscles; the corresponding muscles of the uninjured side 
 increase the deformity by acting similarly on the unbroken side of 
 the jaw (Fig. 294). In most cases good results follow immobilization 
 for three or four weeks by a modified Barton bandage using the 
 upper jaw as a splint; tendency to displacement becomes less a few 
 days after the injury. Fixation by a special interdental splint of 
 gutta-percha, such as is made by dentists, though it may be un- 
 necessary, undoubtedly promotes the patient's comfort, and recovery 
 ensues with little or no deformity. Double or compound fractures 
 frequently require operation, with wiring of the fragments. 
 
 Fracture through the neck of the condyle is a serious injury, often 
 leading to ankylosis (p. 659): the external ptyergoid muscle, attached 
 to the condyle, rotates its broken surface forward, and as it is very 
 difficult to replace this by manipulation, operation is indicated. If 
 the fracture is overlooked in children, disuse of the jaw following 
 ankylosis may result in marked retrognathism. 
 
 Fracture of the coronoid process, a very rare accident, is difficult 
 to detect, as separation of the fragment is prevented by attachment 
 of the temporal muscle far down the inner side of the ramus. Treat- 
 ment consists in procuring rest by bandages until acute symptoms 
 subside. 
 
 FRACTURES OF THE BONES OF THE TRUNK. 
 
 Sternum. — This is an unusual fracture, generally due to direct 
 violence, the patient being crushed beneath a fall of earth, etc.; 
 some cases are due to muscular action, such as violent lifting effort, 
 parturition, etc. Visceral injury is to be feared, especially in cases 
 caused by direct violence; it is manifested by hemoptysis, dyspnea, 
 cyanosis, subcutaneous emphysema, etc. The line of fracture usually 
 is transverse, and sometimes consists in a diastasis between the 
 manubrium and gladiolus; more often a true fracture exists above 
 or below this joint, the lower fragment projecting in front of the 
 upper. Attempts, not always successful, are made to reduce the 
 deformity by hyperextension of the spine over a small pillow, and 
 drawing the arms backward. Crepitus may be detected during this 
 manoeuvre. The sternal region is then immobilized by l)road strips 
 of adhesive plaster, passed from axilla to axilla, while the chest is 
 collapsed in expiration. In uncomplicated cases recovery is rapid, 
 union being firm in three or four weeks. Suppuration may follow 
 in case of extravasation into the anterior mediastinum, and is to 
 be treated by intercostal incision or trephining the sternum. 
 
 Fracture of the ensiform process may unite with deformity;, the 
 xiphoid being turned backward and causing gastric distress {xipho- 
 dynia). This is best relieved by excision of the xiphoid. 
 
Fh'AtTLh'ES OF Tin<: HOSES OF THE THINK 
 
 Ribs. Fractures of the ribs dispute with those of tlie clavicle 
 the first place in freciuency amoug all fractures. The injury, 
 couuuonest in male adults, may be caused by direct or indirect 
 violence; in the latter case the force usually is applied antero-pos- 
 teriorly, and the ribs break at their weakest point when the limit 
 of elasticity has l)een reached. The ribs most often broken (usually 
 two or more at once) are those from the fifth to the ninth, usually 
 in the axillary or posterior axillary line. There is great pain on 
 forced ins})iration, and on sudden motion; localized tenderness, 
 sometimes distinct mobility and crepitus. By using a stethoscope 
 crepitus can be detected in almost all cases, and may be traced up 
 to its origin even from a distance. \ isceral complications are unusual 
 but serious; they should be looked for: subcutaneous emphysema 
 indicates j)artial rupture of the lung; hemothorax is a grave compli- 
 cation, and traumatic pneumonia very fatal. 
 
 Treatment. — Treatment comprises immobilization, but rarely con- 
 finement to bed. Broad strips of adhesive plaster are applied, at 
 the end of each forced expiration and 
 with the arm on the affected side depen- 
 dent; they run from below upward, begin- 
 ning at the spine, and extending Just to 
 beyond the midline in front (Fig. 295). 
 Immobilization of both sides of the chest 
 is undesirable. This strapping should be 
 renewed as often as it comes loose, every 
 five or six days; and should be continued 
 for four or five weeks. For the persis- 
 tent pain and neuralgia which sometimes 
 follow these injuries, massage and anti- 
 rheumatic remedies may be tried; the 
 disability seldom persists long. The treat- 
 ment of injuries of the thoracic viscera is 
 considered in Chapter XX (p. 73.3). 
 
 Costal Cartilages. — These sometimes 
 become detached at their junction with 
 the ribs. Treatment is similar to that 
 for fracture of the ribs. 
 
 Pelvic Bones. — These fractures usually 
 are caused by direct violence, and are of 
 interest chiefly from their visceral compli- 
 cations, which are met with in about one- 
 sixth of the cases (Ashhurst, 1909), the 
 general mortality being over 30 per cent. 
 
 The most important are those fractures which break the ring of the pelvis: 
 when the force is received antero-posteriorly, as when a heavy weight 
 knocks a man down and lands on his symphysis pubis, the anterior part 
 of the peh'is is crushed inward, fracturing the rami of the pubes and 
 ischium on one or both sides or bursting the symphysis pubis, and 
 
 Fig. 295. — Adhesive plaster- 
 strapping for fracture of ribs, 
 applied with arm dependent; arm 
 raised before photograph was 
 taken. Episcopal Hospital. 
 
324 FRACTURES 
 
 spreading the halves of the pelvis apart, perhaps causing diastasis of the 
 sacro-iliac joints, or fracture of the ilium through the sacro-sciatic notch 
 (Fig. 296) . When the force is received laterally, the most frequent frac- 
 ture which involves the ring of the pelvis is a vertical fracture in the 
 neighborhood of the symphysis pubis, and one of the ilium behind 
 the acetabulum; but force transmitted through the femur may cause 
 comminuted fracture of the acetabular region, not invohing the yelvic 
 ring. Of fractures which do not involve the pelvic ring those 
 
 Fig. 296. — Fracture of pelvis, from antero-posterior force. Note diastasis of sym- 
 physis; fracture through innominate bone from iliac crest to sacrosciatic notch; 
 separation of sacro-iliac joint. Recovery. Episcopal Hospital. 
 
 detaching one of the iliac crests are most frequent, usually being due 
 to lateral force (Fig. 237), though the anterior superior spine alone has 
 been detached by muscular action. The various fractures are not 
 difficult to diagnose, as displacement usually is quite appreciable to 
 palpation, which should always include rectal or vaginal examination. 
 If displacement is slight, persistent localized tenderness, especially of 
 one of the pubic rami, is a valuable sign; and a skiagraph may aid. 
 Crepitus often is evident on attempts at motion; pain is experienced 
 
FRACTURES OF THE BONES OF THE TRUNK 325 
 
 wlicn the troclianteric regions are erowded together, or when attempts 
 are made to move one innominate bone on tlie otlier. While ojjrnitwii 
 may he re(|nir('d for visceral eom])licatio!is (ru))tnre of urethra, 
 bhidder, abdominal wall, internal luMnorrhage, etc.), the fractures 
 themselves generally unite with little difficulty. The pelvis should 
 be innnobilized by a broad canvas belt or strips of adhesive plaster; 
 and it often is well to secure relaxation of the adductors, sartorius 
 and rectus muscles by keeping the thighs moderately flexed. Some 
 disability may persist from shortening of one lower extremity, due 
 to imperfect replacement of the fragments, or from mol)ility due to 
 diastasis of one of the {)clvic joints. 
 
 Fracture of the Acetabular Rim is a rare injury due to force trans- 
 mitted through the femur, which may become siil)luxated upward 
 and backward. The diagnosis is difficult without a skiagraph. Treat- 
 ment consists in applying weight extension to the femur in the 
 abducted position, after replacing the head in its socket, and main- 
 taining this position for three or four weeks. Use of the limb should 
 not be allowed for ten or twelve weeks after injury. 
 
 Under the name Central Dislocation of the Hip is described a stellate 
 fracture of the acetabulum caused by the head of the femur being 
 driven through it into the pelvis by direct violence acting in the 
 axis of the femoral neck; pregnancy seems to be a predisposing cause. 
 Henschen (1909) has collected 139 cases. Skillern (1911) classifies 
 the lesions as "fractura perforans" and "perforatum," according 
 to the degree of intrapelvic displacement. The diagnosis is made 
 from flattening of the trochanter and relaxation of the supratrochan- 
 teric structures; by palpating the luxated head in the pelvis by a 
 finger in the vagina or rectum; and by recurrence of deformity, with 
 crepitus, after reduction. The intrapelvic spicules of bone should not 
 be replaced until the head of the femur has been withdrawn. The 
 thigh should be dressed in plaster of Paris in a flexed and adducted 
 position, and the patient should bear no weight on the limb for two 
 or three months. 
 
 Fractures of the Sacrum and Ischium are rare. The tuber ischii 
 has been detached by muscular violence. 
 
 Fractures of the Coccyx follow falls or kicks or parturition, and 
 may readily be diagnosed by inserting the index finger into the 
 rectum and grasping the coccyx between this and the thumb, when 
 abnormal mobility and perhaps crepitus will be detected. If forward 
 displacement is persistent, it is best to excise the occcyx at once, 
 since if the bone unites in bad position, or if non-union results, there 
 often ensues in women a train of neurasthenic symptoms constituting 
 the affection known as coccygodynia. This is characterized by local 
 pain, interference w4th defecation, vesical irritability, and sometimes 
 a life of invalidism; all of which may be cured by removal of the 
 entire coccyx at the sacrococcygeal articulation. 
 
326 
 
 FRACTURES 
 
 FRACTURES OF THE UPPER EXTREMITY. 
 
 Clavicle. — The entire upper extremity dei)eiuls on the chivicle 
 for its l)ony connection with the trunk, and this bone, therefore, is 
 
 exposed to all manner of strains 
 transmitted from the periphery. 
 The patient falls on the hand, or 
 on the point of the shoulder, or 
 rarely receives a blow directly on 
 the clavicle, which gives way usually 
 at its weakest part, between the at- 
 tachments of the sterno-mastoid and 
 trapezius on its upper surface, and 
 those of the pectoralis major and 
 deltoid on its lower surface, ap- 
 proximately at its middle, where 
 the two curves of the bone meet. 
 The line of fracture nearly in- 
 variably is oblique from before 
 backward and from without inward ; 
 and as the main function of the 
 bone is to prop the shoulder away 
 from the trunk, giving the humerus a greater range of motion, the 
 main deformity consists in the shoulder falling inward and forward, 
 
 Fig. 297. — Deformity from fracture 
 of left clavicle, much more noticeable 
 than the average case. Episcopal 
 Hospital. 
 
 Fig. 298. — Skiagraph of fracture of clavicle, with slight comminution, from 
 direct violence. Age twenty-three years. Episcopal Hospital. 
 
 toward the trunk, by contraction of the muscles of the axillary folds, 
 while the weight of the upper extremity causes sliglit dropping of 
 
FUM'Tl'RES OF Till': CLAVKLK '.Vll 
 
 the shouldtT. 'V\w iimcr ciul of tlic claNicIc rriiiiiiiis in its normal 
 position, or possibly is raist'd a little hy the steriio-niastoid; and at 
 the outer end of this fraf^nient a depression can be felt, owing to the 
 displacement inward and backward of the outer fragment (Figs. 297 
 and l2i)S). In rare cases this presses on the subclavian vessels or the 
 l)rachial plexus, but in the vast majority of cases the fracture is entirely 
 uncomplicated. Owing to the inward rotation of the shoulder, the 
 vertebral border of the scapula may become prominent. The diagnosis 
 sometimes isdifhcult in cases of green-stick fracture, and in fat, chu})by 
 children, in whom the outlines of the bones may be hard to detect; 
 but e\en in cases where deformity is absent, there will be persistent 
 localized tenderness at the seat of fracture. In cases with deformity, 
 the diagnosis is easy, even the attitude of the patient being more or 
 less characteristic; he carries his head bent toward the affected side, 
 su{)ports the injuretl limb with his other hand, and is unwilling or 
 unable to raise the arm from the side. 
 
 Fractvre of the Outer End of the Clavicle, a much rarer injury, 
 generally is due to direct violence; if the fracture occurs through the 
 coraco-clavicular ligaments there is little displacement, but if external 
 to them, the outer fragment is carried downw'ard and inward, a 
 displacement which, owing to the posterior convexity of the curve 
 at this point, causes the inner fragment to protrude posteriorly, and 
 produces a characteristic deformity. 
 
 Treatment of Fractured Clavicle. — Reduction of the deformity is 
 difficult, and accurate retention of the fragments nearly impossible; 
 nevertheless, such good functional results follow conservative treat- 
 ment that operation is very rarely performed, especially as a scar 
 would be more conspicuous than the moderate amount of deformity 
 which usually follows conservative treatment. By placing the patient 
 fiat on the back, on a hard bed, and with a folded sheet or firm, flat 
 pillow across the bodies of the scapulfe, this will act as a fulcrum 
 and the force of gravity will carry the shoulder backward, rotating 
 the outer fragment out into its normal relation with the inner. If 
 now a small bag of shot were placed over the inner fragment, to 
 press it down against the outer, and the head raised on a pillow 
 to relax the sterno-mastoid, and the upper extremity immobilized 
 by proper bandages; and if the patient could be induced to remain 
 in this position for tw^o or three weeks until union was fairly firm, 
 then recovery without deformity probably would be assured. Cou- 
 teaud (1909) induced 24 patients to submit to bed treatment, and 
 secured excellent results by letting the arm hang down over the side 
 of the bed for the first two days, thus approximating the fragments 
 by keeping the pectoralis major tense. But even a young girl 
 anxious to preserve her neck from trifling deformity rarely will endure 
 such confinement, and it becomes necessary to devise some means 
 of ambulatory treatment; and though by such treatment entire 
 absence of deformity rarely can be secured, yet recovery of function 
 usually is perfect. The indications are to keep the scapula flat 
 
328 
 
 FRACTURES 
 
 against the chest, thus rotating the shoulder and outer fragment 
 away from the chest; to steady the inner fragment by a compress; 
 
 Fig. 29y. — Dressing for fracture of clav- 
 icle: compress over inner fragment; arm 
 in Velpeau position; fold of elbow and 
 chest protected by lint. Episcopal Hos- 
 pital. 
 
 Fig. 300. — Dressing for fracture of 
 clavicle: arm fixed bj- adhesive plas- 
 ter. Episcopal Hospital. 
 
 and to support the weight of the upper extremity. The fact that 
 m^Tiad dressings have been devised to meet these points suflBciently 
 indicates that none of them is entirely efficient. In children a pos- 
 terior figure-of-eight bandage (Fig. n9), drawing the shoulders back- 
 
 
 3 
 
 Fig. 301.^ — Dressing for fracture of 
 clavicle: application of Velpeau ban- 
 dage. Episcopal Hospital. 
 
 Fig. 302. — Dressing for fracture of 
 cla\'icle: Velpeau bandage reinforced by 
 figure-of-eight turns around elbow, shoul- 
 der and axilla. Episcopal Hospital. 
 
 ward, with a compress over the inner fragment, and with the arm 
 supported in a sling, usually gives very satisfactory results. In adults. 
 
FRACTURES OF THE CLAVICLE 
 
 329 
 
 ill whom the parts arc more (hfficMilt to fix, I prefer to use the dressing 
 indicated in the aeeonii)anying ilhistrations. After strap])ing a com- 
 press over the inner fragment, and fixing the sc;ii)ula l)y a broad stra|) 
 of adhesive plaster passing across tlie back to the axilla of the sound 
 side, a piece of lint is placed in the elbow, the axilla is dusted with 
 
 Fig. 303. 
 
 -Fracture of scapula through body and near angle. Age twenty-four 
 years. Episcopal Hospital. 
 
 boric acid powder, and a large fold of lint is fastened across the chest 
 (Fig. 299) ; the arm is then slung to the chest by a board band of 
 adhesive plaster (Fig. 300) ; a Velpeau bandage is then applied, fixing 
 the arm to the chest (Fig. 301); this is reinforced by turns of the 
 bandage beneath the elbow, crossing each other over the injured 
 
330 FRACTURES 
 
 shoulder, and passing beneath the axilla of the opposite side (Fig. 302). 
 The last turns support the upper extremity and pull the inner frag- 
 ment down, forming a valuable addition to the Velpeau bandage. This 
 dressing need not be renewed until it comes loose — usually not for six or 
 seven days; and at the end of four weeks may be discontinued, and 
 the arm merely carried in a sling, its active use being prohibited 
 until six wTcks from the time of the accident. Rarely is any after- 
 treatment required, normal use restoring function in a short time. 
 
 Scapula. — This generally is broken by direct violence. Fractures of 
 the body of the scapula (Fig. 303) usually are more or less transverse, 
 and the fragments are not much separated: but by fixing the angle 
 with one hand, and manipulating the shoulder with the other, both 
 crepitus and mobility may be detected in most cases. Disability 
 rarely is marked. Treatment consists in immobilizing the upper 
 extremity for four or five weeks. Fractures of the acromion process 
 are more frequent than those of the body of the bone, and are to 
 be diagnosed by persistent localized tenderness following direct 
 injury, sometimes by crepitus, but rarely by distinct mobility unless 
 the line of fracture is distinctly posterior to the acromio-clavicular 
 joint. Skiagraphic confirmation is desirable, and will serve to dis- 
 tinguish this injury from separation of the epiphysis, which probably 
 is a more frequent injury, but clinically indistinguishable from frac- 
 ture. Immobilization for about four weeks is sufficient. Fracture 
 of the coracoid process may occur from muscular action, or rarely 
 from direct violence. It is a rare injury, but usually may be detected 
 by painstaking examination, unless the patient is very muscular or 
 fat. The process is pulled downward into the axilla by the muscles 
 attached to it, and often may be felt here, while it is absent from its 
 normal site just below the outer third of the clavicle. If crepitus 
 cannot be obtained in confirmation of apparent displacement and 
 mobility, a skiagraph must be relied on for diagnosis. Fracture 
 through the surgical ueck of the scapula, the line of fracture passing 
 through the suprascapular notch and detaching both the coracoid 
 and glenoid processes, is a rare injury which may be mistaken for 
 dislocation of the shoulder; in dislocation, however, the arm hangs 
 away from the side, mobility is decreased or even absent, and no 
 crepitus can be obtained; in fracture, though the humerus is carried 
 downward and inward with the detached fragment by the pull of 
 the axillary muscles and those attached to the coracoid, thus pro- 
 ducing a hollow beneath the acromion, yet attentive examination 
 will show that there is in the axilla not the isolated head of the 
 humerus, but a bony mass composed of coracoid, glenoid, and 
 humerus, and that the coracoid moves with the humerus and is 
 detached from the scapula. Moreover, there is crepitus and abnormal 
 mobility; and when the deformity is reduced, it recurs at once; none 
 of which phenomena are present in dislocation. Finally, skiagraphic 
 evidence may be called in aid, and usually w^ill determine the matter 
 without doubt. Treatment consists in reducing the deformity as 
 
FRAC.TVRKS OF THE HUMERUS 
 
 331 
 
 far MS i)()ssil)l(\ n\n\ imiiu)l)ili/jiig the iij)ikt extremity as in fractures 
 of the claxicU'; a folded towel or other flat support should he ])laced 
 in tlie axilla to aid in retaining the fragment in place, {{eduction 
 usually is imperfect, callus may be exuberant, and the restoration 
 of function may be much delayed, perhaps from involvement of the 
 suprascapular nerve. . 
 
 Humerus. — It is customary to divide these injuries into fractures 
 of the upper end, those of the shaft, and those of the lower end of 
 the l)one. 
 
 Fig. 304. — Fracture of anatomical neck of humerus. At;r lill^ -Iniir years. 
 Episcopal Hospital. 
 
 Fractures of the Upper End of the Humerus. — Fracture of the 
 anatomical neck is a rare injury; the detached hemispherical frag- 
 ment is wholly or largely intra-articular, and is displaced tow^ard the 
 axilla, turning at right angles to the shaft (Fig. 304). Sometimes 
 the fragment is forced through the capsule of the shoulder-joint, and 
 lies almost subcutaneously in the axilla. Palpation then detects 
 the head in its abnormal position, while the tuberosities retain their 
 
332 
 
 FRACTURES 
 
 normal relations to the shaft of the humerus and to the acromion. 
 Crepitus may be elicited by pressing the detached head outward 
 against the shaft; but unless the head is clearly palpable a positive 
 diagnosis is very difficult without a skiagraph. Most cases so diag- 
 nosed turn out to be high fractures of the surgical neck. If the head 
 is displaced so far as to be almost subcutaneous, it is best to remove 
 it by incision; function will be much better than if the fragment 
 
 Fig. 305. — Separation of upper opipliysis of humerus. Typical displacement. _ Note 
 pyramidal shape of upper end of diaphysis, and new formed bone beneath periosteal 
 bridge on inner side of fracture, which has not been reduced. Age nine years. 
 
 remains as a foreign body to excite periarthritis. In cases where 
 displacement is slight, the treatment described below for fracture 
 of the surgical neck is efficient. Fracture of the greater tuberosity 
 occasionally occurs from muscular action, and more rarely still from 
 direct violence; a sprain fracture is a not unusual lesion accompanying 
 dislocation of the shoulder. The fragment is drawn outward, upward, 
 and backward by the external rotator muscles. Reduction may be 
 easy, but usually is very difficult to maintain even if the humerus is 
 
FRACTURES OF THE HUMERUS 
 
 333 
 
 dressed in Jilxluetioii. Ilenee ojjerative fixation by periosteal suture 
 of ehroniie eatf,nit may be advisable. In other cases, firm bandaf,'ing 
 over a shoulder-eap may keep the frajiment in place. Separation of the 
 upper epiphysis of the hunienis: This epiphysis may be separated at 
 any age until it unites with the diaphysis, not later than twenty- 
 five years. The injury is commonest, however, at or a})out fifteen 
 years of age, though sometimes it occurs as an o})stetrical injury. 
 The upper end of the diaphysis is pyramidal in shape (Fig. 305), 
 and the epiphysis fits over it like a cap. The epiphyseal line passes 
 on the surface of the bone just 
 beneath the greater tuberosity, 
 irregularly inward, being intra- 
 articular on the inner side of the 
 humerus, so that the detached frag- 
 ment (the epiphysis) is somewhat 
 larger than that in fracture of the 
 anatomical neck, but smaller than 
 that in fracture of the surgical neck. 
 The displacement of the epiphysis 
 depends largely on muscular ac- 
 tion: the subscapularis in front and 
 the infraspinatus and teres minor 
 behind draw the epiphysis directly 
 inward, while the supraspinatus, 
 being unopposed, tilts its outer 
 margin (the greater tuberosity) 
 upward; the diaphysis usually, but 
 not always, is drawn inward and 
 forward, by the muscles of the 
 axillary folds, and in typical cases 
 is prominent beneath the anterior 
 fibres of the deltoid. Fracture of 
 the surgical neck of the humerus is 
 the most frequent injury of the 
 humerus in adults, and is produced 
 usually by a fall or blow on the 
 outer surface of the shoulder. The 
 region included in the surgical neck 
 is that from the epiphyseal line 
 
 above, to the upper border of the insertions of the pectoralis and teres 
 major muscles below. "High fractures of the surgical neck," some- 
 times called "fractures through the tuberosities," are in all respects 
 similar to epiphyseal separations, but occur after ossification in the 
 epiphyseal line. The typical displacement in ordinary fracture of the 
 surgical neck consists in the lower fragment being drawn inward by 
 the axillary muscles, and somewhat upward by. the deltoid, triceps, 
 and muscles running from the humerus to the coracoid process. Unless 
 impaction is present the diagnosis is not difficult; the tuberosities do 
 
 Fig. 306. — Skiagraph of impacted 
 fracture of surgical neck of humerus, 
 (See Fig. 307.) Episcopal Hospital. 
 
•)0 1 
 
 oo4 
 
 FRACTURES 
 
 not rotate with the shaft, and deformity, mobihty, and crepitus are 
 easily detected. 
 
 Treatment of Frdciiircs of the Uyper Eiul of the Humerus. — After 
 washing the parts in alcohol, a modified Fergusson's dressing (1842) 
 is applied as follows: a primary roller is applied from the metacarpus 
 up to the site of fracture, with the elbow flexed; this prevents swelling 
 of the hand and forearm and adds much to the patient's comfort. 
 The fracture is then reduced, by traction downward in the axis of 
 the body, manipulating the upper end of the shaft so as to pusli 
 
 Fig. 307. — Impacted fracture of surgical neck of humerus after reduction under 
 an anesthetic. Compare Fig. 306. Episcopal Hospital. 
 
 it out and l)ring it into contact with the u})i)er fragment. Then a 
 moulded shoulder-cap of binder's-board, well padded, is placed over 
 the shoulder, reaching almost to the elbow, and is held in place by 
 a spica bandage of the shoulder (see Fig. 311). A sufficient amount 
 of raw cotton is then placed between the arm and chest to fill up the 
 natural hollow, and to keep the shaft of the humerus from being dis- 
 placed inward. The arm is then bandaged to the thorax, and a sling 
 is applied to support the wrist. By leaving the elbow unsupported, 
 thus gaining the advantage of extension by the weight of the limb, 
 
FRACTURES OF TIIF HUMFRUS 
 
 335 
 
 tluTo is loss (Iniiijor of displacement of the fragments. This dressing 
 should be renewed about twice weekly for five weeks. 1 have never 
 
 Fig. 
 
 308. — Fracture of humerus above insertion of deltoid, lower fragment displaced 
 outward and upward by that muscle. Episcopal Hospital. 
 
 found it necessary to dress the arm in abduction in order to secure 
 better apposition of the fragments. 
 
336 
 
 FRACTURES 
 
 In cases of fracture of the surgical neck impacted with deformity 
 I believe it usually is better, except in the very old or feeble, to 
 anesthetize the patient, free the impaction (usually easy) by forced 
 rotation, and reduce the deformity as far as possible (Figs, 306 and 
 307). 
 
 Fractures of the Shaft of the Humerus. — These may occur at any 
 level, usually from direct violence, but occasionally from muscular 
 action. In 1906 I found references to 96 such cases, mostly due to 
 
 Fig. 309. — Fracture of lower third of shaft of humerus. Episcopal Hospital. 
 
 throwing a ball, the two ends of the humerus apparently being twisted 
 apart by violent rotation of the upper end, opposed by the inertia of 
 the rest of the limb. Fractures from direct violence are more apt 
 to be transverse and comminuted, than those caused by indirect vio- 
 lence, which are more or less oblique or spiral. If the fracture is 
 above the insertion of the deltoid, there is a tendency for the lower 
 fragment to be carried up and out by this muscle; while the upper 
 fragment is pulled inward by the axillary muscles (Fig. 3()<S); but if 
 the fracture is below the insertion of the deltoid, the reverse is 
 
FRACTURES OF THE HUMERUS 
 
 337 
 
 Fig. 310. — Drpssitij; for fraoture of shaft of 
 humerus: coaptation splints around scat of frac- 
 ture. Episcopal Hospital. 
 
 the case, the upper fra<i;ment l)einj,^ disphieed outward by the deltoid, 
 
 while the lower is tlrawii up toward the axilhi by the bieeps, trieeps, 
 
 and coraco-braehialis. In fractures of the hwer third of the shaft, 
 
 which are rarer, there is an^juhir deformity forwards, owiujj; to the 
 
 actiou of tiie luuscles arisin<i; 
 
 from the condyles of the 
 
 liumerus which keep the 
 
 elbow flexed, and thus brin<j; 
 
 the upper end of the lower 
 
 fraj;inent forward, as the arm 
 
 falls by the side (Fiji :><>!)). 
 
 Tn all fractures of the shaft 
 
 the diagnosis is easily mad(\ 
 
 and reduction is not difficult 
 
 to secure nor to maintain if 
 
 an efficient dressing is applied. 
 
 That which I have used with 
 
 perfect satisfaction is shown 
 
 in the accompanying illus- 
 trations. A primary roller 
 
 is applied up to the elbow; 
 
 the arm is surrounded by 
 
 raw cotton; three coaptation 
 
 splints of binder's-board are 
 
 adjusted around the arm, one anteriorly, one posteriorly, and one 
 
 externally (Fig. 310), and are secured by continuing the bandage 
 
 up to the axilla; over this a shoulder-cap is next adjusted (Fig. 
 
 311), and fixed by a spica of the shoulder (Fig. 312); the arm is 
 
 finally bandaged to the chest 
 and a wrist sling applied 
 leaving the elbow unsup- 
 ported to give extension to 
 the seat of fracture (Fig. 313). 
 In rare cases with overlapping 
 of very oblique fractures, 
 weight extension can be ap- 
 plied as an ambulatory dress- 
 ing (F^ig. 314). If the fracture 
 is in the lower third of the 
 humerus an anterior angular 
 splint (Fig. 315) may be used, 
 either alone, or in addition 
 to the use of a shoulder-cap; 
 but in fractures above this 
 region any attempt to im- 
 mobilize the elbow will result 
 
 in transferring every motion of the forearm to the seat of fracture 
 
 in the humerus, and delayed union frequently will result. 
 22 
 
 Fig. 311. — Dressing for fracture of shaft of 
 humerus: shoulder-cap applied. Episcopal 
 Hospital. 
 
338 
 
 FRACTURES 
 
 Fractures of the Lower End of the Humerus. — These are much more 
 frequent in children than in adults. The usual cause in children 
 
 Fig. .312. — Dressing for fracture of shaft 
 of humerus, shoukler-cap secured by 
 spica bandage of shoulder. Episcopal 
 Hospital. 
 
 Fig. .31.3. — Dressing for fracture of 
 shaft of humerus completed and wrist 
 sling applied. Episcopal Hospital. 
 
 is a fall on the outstretched hand; in adults such an accident is more 
 apt to cause dislocation if the lesion occurs at the elbow. Direct 
 
 Fi"G. 314. — Weight extension for frac- 
 ture of shaft of humerus. Episcopal 
 Hospital. 
 
 Fig. 31-5. — Anterior angular splint applied 
 to elbow. Episcopal Hospital. 
 
 injury, often resulting in compound or comminuted fractures, is a 
 more frequent cause of elbow fractures in adults. There are several 
 
FRACTURES OF THE ICLBOW 
 
 339 
 
 distinct types of Fracturt' lioro, which may he conveniently c 
 thus (PV •^••'): 
 
 1. Sni)racoii(lyIar I'Vactures ^ 
 
 2. Diacondyhir Fractures ^ These are tlie most frequent v 
 
 3. External Condyle J 
 
 4. Epiphyseal Sei)aration. 
 
 5. Internal Condyle. 
 
 (). IntcTcondylar. T or Y. 
 
 7. Ei)itrochlea. 
 
 The lower epiphysis of the humerus is de\elopcd from a 
 of centres, and is l)est studied in a series of skia,<j;raphs of 
 elbows: the centre iur the capitellum 
 of the humerus appears during the 
 first year of life, that for the head of 
 the radius becoming visible in the 
 sixth year, closely followed by that 
 for the epitrochlea of the humerus. 
 These centres are well shown in Fio;. 
 
 assified 
 
 arieties. 
 
 number 
 normal 
 
 Fig. 316. — Diagram to show classification of 
 fractures of the lower end of humerus. 
 
 I'k;. :517. — Skiagraph showing lower 
 epiphysis of humerus at five years 
 and eleven months (antero-posterior). 
 Episcopal Hospital. 
 
 olT. The centre for the trochlea appears at eleven years, and that 
 for the olecranon a little later. Fig. 318 is a lateral view of the 
 normal elbow at eleven years. 
 
 1. Supracotuh/lar Fractures usually are due to a fall on the out- 
 stretched hand, the elbow being suddenly hyperextended, and the 
 lower end of the humerus torn off partly by ligamentous distraction, 
 partly by the force of the blow, which generally displaces the fragment 
 posteriorly. The line of fracture is oblique from abo\e downward and 
 forward (Fig. 319). Impaction is unusual. When the elbow is extended 
 it is found that lateral motion is possible between the forearm and 
 
340 
 
 FRACTURES 
 
 arm, the "carrying angle" is lost, antero-posterior movements give 
 crepitus, and often the lower end of the npper fragment can be felt 
 
 Fig. 318. — Skiagraph of lower epiph.ysis of humerus at eleven years (lateral). 
 Episcopal Hospital. 
 
 Fk 
 
 319. — Skiagraph of supracondylar fracture of humerus; before reduction, 
 elbow dressed on anterior right-angled splint. Episcopal Hospital. 
 
FRACTURED OF THE ELBOW 
 
 341 
 
 ill the 1)011(1 of tlie dhow. Tlie coiulylcs retain tlieir normal relation 
 with the oleeranon, which is not the ease in posterior dislocation 
 at the elbow, for which the deformity of fractnre sometimes is mis- 
 taken. 
 
 2. Diacoiid 1/1(1 r Fractures are transverse fractures between the 
 level of supracondylar fractures and that of the epi})hyseal line. 
 They usually follow a fall on the extensor surface of the forearm, 
 the elbow being flexed, and often are impacted. The line of fracture 
 traverses the thin layer of })one separatin*^ the olecranon and coro- 
 noid fossjK. Diagnosis is based on the history, the signs of elbow 
 
 Fig. 320. — Supracondylar fracture of humerus shown in Fig. 319, after reduction 
 dressed in position of hyperflexion. Episcopal Hospital. 
 
 injury, and skiagraphic examination. A rare form described by 
 Posadas (1901) consists in forward displacement of the lower fragment 
 and posterior dislocation of the bones of the forearm. 
 
 3. Fractures of the External Condyle usually follow falls on the out- 
 stretched hand; as the ulna does not articulate with the hand, the 
 force is transmitted tlirough the radius directly to the external con- 
 dyle, thus explaining the greater rarity of fractures of the internal 
 condyle. The line of fracture extends into the joint, somewhere 
 between the capitellar and trochlear surfaces (Fig. 321); lateral 
 
342 
 
 FRACTURES 
 
 mobility usually is present, and crepitus can he detected either in this 
 way or by moving the external condyle with thumb and finger directlv 
 
 Fiv,. 321. — Skiagraph of fracture of external condyle of humerus. 
 
 upon the shaft. Under the name epicondylitis, ^lombtirg (1910) has 
 described what corresponds to a sprain-fracture of the external 
 
 epicondyle. I have seen several 
 cases appparently of this nature. 
 4. Separation of the Entire 
 Lower Epiphysis may occur until 
 its union with the diaphysis, 
 from fifteen to seventeen years, 
 but usually occurs before thirteen 
 years of age. The epiphyseal 
 line is largely intra-articular, pass- 
 ing below the coronoid fossa. A 
 small shell of bone often is de- 
 tached from the diaphysis also 
 (Fig. 322) ; if this is not the case, 
 and the line of fracture passes 
 directly along the epiphyseal line 
 (cartilage), it will not be visible 
 in a skiagraph. ^lany epiphyseal 
 separations are wrongly classed as 
 mere sprains, because the skia- 
 graph shows nothing abnormal. 
 The trauma producing the injury 
 ... . often is slight, and deform it\' 
 
 ■i'SJ. — >kiagrai)h ot epiphyseal , • i c -i ' 
 
 separation of left humerus. rarely IS present ; but failure to 
 
 Fi( 
 
FRACTURES OF THE El. HOW 
 
 343 
 
 recognize tlic lesion may l)e disastrous. The diagnosis is based on a his- 
 tory of injury, on indistinct, nuifflcd crepitus, extreme pain on forced 
 extension and persistent hx-aiized tenderness in the flexure of theelhow. 
 
 Fk;. 323. — .Skiagraph of fracture of internal condyle of humerus. Episcopal 
 
 Hospital. 
 
 5. Fractures of the Internal Condyle. — These are rare in children, 
 but being caused usually by direct violence (falls on the acutely 
 flexed elbow) are relatively more frequent in adults. The usual 
 line of fracture is shown in Fig. 323. The disability is extreme, the 
 support of the ulna being destroyed: the forearm falls against the 
 side, causing loss of the carrying angle, and the internal condyle 
 may be moved antero-posteriorly on the shaft. 
 
 6. Intercondylar Fractures are very rare, especially in children. 
 They are caused by great violence, almost always direct, the ulna 
 being driven up between the condyles and separating them from each 
 other and from the shaft (Madelung), resulting in a Y-fracture; or the 
 diaphysis splitting into halves the fragment due to a supracondylar 
 fracture (Gurlt, 1862), resulting in a T-fracture. The diagnosis rests 
 on the independent mobility of the condyles on each other and on 
 the shaft. 
 
344 
 
 FRACTUEES 
 
 7. Fractures of the Ejntrochlea (Fig. 324) often are epiphyseal sepa- 
 rations of this centre, as it does not unite witli the diaphysis until the 
 
 Fig. .324. — Skiagraph of fracture of epitrochlea of humerus. Episcopal Hospital. 
 
 eighteenth year. The injury usually is due to muscular or ligament- 
 ous action, and is a not unusual accompaniment of posterior dislocation 
 of the elbow. 
 
 Fig. 325. — Fracture of capitellum of humerus, from fall on elbow. Age thirtj'-eight 
 years. Patient under care of Dr. Jopson in University Hospital. Fragment replaced 
 by arthrotomy. Excellent result. 
 
 Of other rarer fractures of the lower end of the humerus, those of the 
 capitellum (Fig.' 325) are of most importance; the fragment usually 
 
FRACTURES OF THE ELBOW 
 
 345 
 
 is displaced into tlic Ixnid of the elbow, and seldom can be replaced 
 without incision. 
 
 Treatment of Fractures- of the Lower End of the IIunieruff.—A^ these 
 fractures are all close to the joint, and many of them wholly or in 
 part intra-articular, it is extremely important to secure early and 
 aecurat(> reduction of the frat^ments, in order to lessen the amount 
 of callus formed, and thus i)ermit restoration of perfect function. 
 Intelligent man(ruvres of reduction can l)e undertaken only after 
 a correct diagnosis has been made, and 1 have dwelt upon the indi- 
 vidual lesions so fully not because their treatment is materially 
 ditfcrent, but because accurate 
 reduction must be secured at the 
 earliest possible moment; only in 
 this way can surgeons hope to 
 remove the oi)pr()l)rium which has 
 long attached to these injuries and 
 which 1 believe is quite unnecessary. 
 
 a - 
 
 Fig. 32G. — Diagram of carrying angle. 
 (After Potter.) 
 
 Fig. 327. — Patient shownng normal 
 carrying-angle on right and gunstock 
 deformity on left. Children's Hospital. 
 
 Supracondylar fractures form the large proportion of these injuries, 
 and I shall discuss the treatment of this variety at greatest length. 
 The muscles arising from the condyles of the humerus are the only 
 muscles attached to the fragment, and they tend to keep it flexed 
 on the forearm. Motion transmitted from the forearm takes place 
 between the fragment and the shaft of the humerus, not in the elbow- 
 joint. The fragment usually is displaced posteriorly. All these 
 considerations, as well as clinical experience, teach that it is better 
 to dress these injuries with the elbow flexed. The fracture is reduced, 
 by hyperextension of the elbow to relax the triceps, then by extension 
 
346 
 
 FRACTURES 
 
 and counter-extension to bring the fragment forward into its normal 
 relation with the shaft. It is kept reduced by hyperflexion of the 
 elbow (flexion as acute as possible), thus bringing the insertion of the 
 triceps anterior to the humerus, and making this nuiscle act as a 
 sling in holding the fragment in place. In order to preserve the 
 "carrying angle," which is formed by an equal obliquity of the 
 articular surfaces of the humerus and the bones of the forearm (Fig. 
 326), it is extremely important to flex the forearm upon the arm 
 directly in the sagittal plane, and to keep it in that position, thus 
 avoiding internal rotation of the lower fragment. When there is 
 
 Fig. 328. — Patient showing cubitus valgus after recovery from fracture of 
 internal condyle. Episcopal Hospital. 
 
 loss of the "carrying-angle" (cubitus varus, Fig. 327) the forearm 
 falls to the outer side of the arm when the elbow is hyperflexed. 
 Increase of the "carrying angle" (cubitus valgus) is a less conspicuous 
 and much less disabling deformity (Fig. 32S). 
 
 Other fractures of the lower end of the humerus must all be 
 reduced accurately by suitable manipulations, which cannot be 
 described at length here. All may be kept reduced by dressing the 
 elbow in hyperflexion. The method in which this is to be done is 
 sufficiently indicated in the accompanying illustrations: the arm 
 and forearm act as splints to each other, and when they are bound 
 to each other they may be rotated inward as one bone, and the hand 
 slung around the neck (Figs. 329, 330, 331). The elbow is dressed 
 
rnACTURKS OF THE KLIiOW 
 
 347 
 
 Fig. 329. — Dressing to maintain elbow in hyi)rrflexion, first static. Ei)iscopal Hospital. 
 
 Fig. 330. — Dressing to maintain elbow Fig. 331. — Dressing to maintain elbow 
 
 in hyperflexion, second stage. Episcopal. in hyperflexion, completed. Episcopal 
 Hospital. Hospital. 
 
348 
 
 FRACTURES 
 
 about twice weekly, the hyperflexion being reduced at each dressing 
 only enough to permit washing the flexure of the elbow, and re-inser- 
 tion of a fold of lint. At the end of the second week the elbow may 
 be dressed in less acute flexion, and at the end of four weeks may be 
 carried in a sling for a week or ten days. No massage or passive 
 motion is necessary to restore function if accurate reduction has 
 been secured; but full extension may not be secured for several 
 months. 
 
 Ulna. — Fractures of this bone are caused mostly by direct violence. 
 Fractiires of the olecranon, however, may occur from muscular action 
 in sudden flexion, or as a "compression" fracture in hyperextension 
 of the elbow; unless the aponeurotic insertion of the triceps is torn 
 widely there is not much separation, but mobility and crepitus usually 
 are distinct. In simple fractures operation rarely is indicated, as 
 by strap})ing the fragment on to an obtuse angled splint (Fig. 332) 
 reduction usually is easy; even if accurate reduction is not secured 
 
 Fig. 332. — Dressing fracture of olecranon on anterior obtuse angled splint. Padding 
 omitted to show splint better. Episcopal Hospital. 
 
 at the first attempt, it is remarkable how much imp^o^•ement in 
 position is obtained in a few days. This is one of the few fractures 
 which prove an exception to the general rule that prompt reduction 
 is necessary for recovery of good function. In compound fractures, 
 operation is preferable (Figs. 333 and 334). Separation of the olecranon 
 epiphysis, which appears first in a skiagraph from ten to eleven years, 
 is a rare injury, requiring the same treatment as fracture. Fracture 
 of the coronoid process is a rare accompaniment of posterior dis- 
 location of the elbow, and is to be suspected when it is diflScult to 
 maintain reduction of this lesion. The fragment, which is partly 
 intra-articular, and which has the brachialis anticus attached only to 
 its base, seldom is much displaced. Treatment consists in dressing 
 the elbow in hyperflexion for a couple of weeks, and then allowing 
 gradual extension. Fractures of the shaft of the ulna are very dis- 
 abling, as the ulna forms the main part of the elbow-joint, and through 
 the interosseous ligament supports the radius and hand. Patients 
 
FRACTURES OF THE ULNA 
 
 349 
 
 wltli fracture of tlu> ulna rarely can hold the forearm out for an 
 examination without sui)i)ort from the other hand. In the ui)i)er 
 part of the shaft the displacement often is backward, owing to the 
 
 Fig. 333. — Skiagraph of compound fracture of olecranon. Treated by operation. 
 (See Fig. 334.) Episcopal Hospital. 
 
 pull of the triceps (Fig. 33(3) ; but when the trauma has been great, 
 the ulna may be displaced anteriorly, the continuation of the force 
 causing forward dislocation of the head of the radius (Fig. 406). In 
 the lower part of the shaft, the pronator quadratus draws the lower 
 
 Fig. 334. — Skiagraph of compound fracture of olecranon, after suture of aponeurosis 
 of triceps with chromic catgut. Age twenty-five years. Episcopal Hospital. 
 
 fragment against the radius, producing a deformity very difficult to 
 overcome, though sometimes extreme abduction of the hand, by the 
 use of a reverse Bond splint (one made for the other hand), may 
 
350 
 
 FRACTURES 
 
 succeed (Skillern, 1910). Green-dick fractures of the uhin are frcHjuent, 
 but these, as well as complete breaks of the middle and lower thirds, 
 are frequently accompanied by fracture of the radius. Fracture 
 of the styloid process of the ulna often accompanies fractures of the 
 lower end of the radius. 
 
 Owing to the subcutaneous position of the ulna the diagnosis of 
 these various fractures presents few difficulties; and all may be 
 
 treated by immobilizing the fore- 
 arm on a straight splint, with 
 pads so adjusted as to o\ercome 
 the tendency to displacement. 
 
 Radius. — Fractures of the head 
 of the radius usually are caused 
 by a fall on the over-extended 
 ]:)alm, the force transmitted 
 through the radius making it 
 impinge with great force on the 
 external condyle, and splitting 
 the head of the radius into two 
 or more parts (Fig. 335). The 
 symptoms are persistent localized 
 pain and tenderness, indistinct 
 crepitus on rotation, but rarely 
 appreciable mobility or displace- 
 ment. A skiagraph usually is 
 necessary for confirmation, but 
 unless several are taken in differ- 
 ent planes, the line of fracture 
 may not be visible. If there is 
 a loose fragment it is better to 
 excise it, as non-union is frequent. 
 In most cases, however, it is 
 sufficient to immobilize the fore- 
 arm for about four weeks in fnll 
 supination on an anterior angular 
 splint (Fig. 315). Fractures of the 
 neck of the radius result from much 
 the same causes as those of its head, but may accompany fractures 
 of the olecranon from a fall on the flexed forearm; or may be accom- 
 panied by a fracture of the shaft of the ulna (Fig. 336). These 
 fractures are apt to be impacted, and it is not desirable to disturb 
 the impaction lest non-union result, the upper fragment being so 
 small as to be uncontrollable. The forearm should be dressed in full 
 supination. Fractures of the shaft of the radius are unusual except 
 when accompanied by fracture of the ulna. If the fracture is above 
 the insertion of the pronator radii teres, this muscle will pronate the 
 lower fragment while the upper will be supinated and flexed by the 
 biceps; to reduce the deformity the forearm should be dressed in full 
 
 Fig. 335. — Fracture of head of radius. 
 Age twenty-six years. Episcopal Hospital. 
 
FRAl'TURI'JS OF THE RADIUS 
 
 351 
 
 supination (Lonsdale, KS;JS), on an anterior splint, with the elhow 
 flexed. If the fraeture oecurs below the insertion of the pronator 
 radii teres this nuiscle will keep the ui)per fragment senii-pronated, 
 and the lower fragment should he brought into that position before 
 the splint is applied, and so dressed. 
 
 Fig. 330. 
 
 -Fracture of neck of radius complicating fracture of upi)er half of 
 ulna. Episcopal Hospital. 
 
 Fmriurcs of the Lower End of the Radius.— The typical^ fracture 
 in this region, one of the most frequent in the entire body, is known 
 by the name of Colles (1814). Colles's Fracture results almost invari- 
 ably from a fall on the over-extended palm, and the break occurs 
 about 1 or 2 cm. above the wrist-joint; the lower fragment is dis- 
 placed toward the extensor surface, often being impacted into the 
 posterior surface of the shaft, the lower end of which protrudes 
 
 Fig. 337. — Colles's fracture of radius, showing silver-fork deformity; recent 
 accident in patient of sixteen years. Episcopal Hospital. 
 
 beneath the flexor tendons. This typical displacement is known as 
 the "silver-fork deformity," and Fig. 337 shows that it is well merited; 
 often, how^ever, deformity is much less evident. In addition to the 
 antero-posterior displacement (Fig. 338), there usually is moderate 
 radial deviation of the hand, rendering the head of the ulna promi- 
 nent (Fig. 339). A fracture of the ulnar styloid is a frequent 
 accompaniment. Crepitus and mobility seldom are present, and the 
 
352 
 
 FRACTURES 
 
 diagnosis usually is made from the deformity and localized pain 
 and tenderness; but even in cases without visible deformity the 
 lesion should be suspected from the 'nature of the injury. If un- 
 recognized as a recent injury the deformity may become much more 
 evident in the next twenty-four hours, and the patient and the surgeon 
 whom he consults then, are apt to blame one who failed to recognize 
 a fracture the dav before. Treatment consists in reduction as soon 
 
 Fig. 33S. — Skiagraph (lateral 
 view) of unreduced CoUes's fracture 
 of radius, slight silver-fork deform- 
 i'.y; duration three weeks. (See 
 Fig. 339.) Episcopal Hospital 
 
 Fig. 339. — Skiagraph (antero-posterior view) 
 of unreduced Collcs's radial fracture of radius, 
 with displacement of lower fragment, and 
 fracture of the styloid process of the ulna. (See 
 Fig. 338.) Episcopal Hospital. 
 
 as possible after the injury (Fig. 340) : this is accomplished by hyperex- 
 tension and forced adduction of the lower fragment (Fig. 341), followed 
 by direct pressure forward on it, with counter-pressure backward on 
 the lower end of the upper fragment. If impaction is very firm, an 
 anesthetic maybe required. Usually more force is necessary even in 
 cases of slight impaction than the inexperienced surgeon expects; and 
 though failure to secure accurate reduction may not materially 
 interfere with use of the hand, some deformity will remain, and 
 
FRACTURES OF THE RADIUS 
 
 353 
 
 ill many cases tlir hand is iKTnianently weakoncd. Any drossinj; 
 which will hold the l"ra<,Mncnts in i)hK'c may then he appHed, the 
 
 Fig. 340. — Skiagraph of recent Colles's fracture of radius and fracture of styloid 
 process of ulna, after reduction. Episcopal Hospital. 
 
 forearm being in semi-pronation or full supination, never in complete 
 pronation. Supination is the movement which is most difficult 
 
 Fig. .341. — Reduction of Colles's fracture, of left radius. Episcopal Hospital. 
 
 to regain, and if the hand is dressed in pronation, it may never be 
 regained; whereas if the fracture is put up in full supination, all 
 
354 FRACTURES 
 
 subsequent activities of the hand will be such as to encourage return 
 of pronation. In cases where no tendency exists for recurrence of dis- 
 placement, a straight posterior splint (Tig. 342 j makes a comfortable 
 
 Fig. 34:2. — -Posterior splint for Colles's fracture. Padding omitted for photograph. 
 
 Episcopal Hospital. 
 
 dressing; for the first week this should extend to the proximal inter- 
 phalangeal joints, but may then be shortened to the metacarpo- 
 phalangeal articulation^. In cases where reduction is difficult to 
 
 Fig. .343. — Bond's splint. 
 
 maintain. I prefer to use a Bond splint CFig. 343), on the flexor 
 surface, with two compresses, one on the dorsal surface over the lower 
 fragment, and the other on the flexor, to fill up the natural concavity 
 
 Fig. 344. — Bond splint for Colles's fracture. Padding omitted from splint, and 
 leather guard removed to show compresses; note their form and position. Episcopal 
 Hospital. 
 
 of the forearm above the wrist, and to retain the upper fragment in 
 proper position (Fig. 344). Splint support should be continued for 
 four weeks. 
 
FRACTURES OF THE FOREARM 
 
 355 
 
 Other FraHiiirs of the Lower End of the, Radius. — Barton's Fracture 
 (1838) is tlu' name ijivcn to (letuchineiit of the dorsal portion of tlie 
 articular surfacr of the radius; diagnosis without a skiaj^^raph is 
 difficult. Reverfied Colle.s's Fracture, in which the lower fragment is 
 displaced toward the flexor surface, was described in 1865 by Cal- 
 lender; the displacement was named "gardener's spade deformitx" by 
 Roberts (1897). Chauffeur's Fracture, so named because often received 
 while "cranking" an automobile, may be of various types, the most 
 frequent of which is one splitting off the outer surface of the articular 
 surface of the radius through the base of the styloid process (Fig. 345). 
 Separation of the lower radial epiphysis (Fig. 28(ij can be certainly 
 distinguished from Colles's fracture only by radiograpli>-. All these 
 lesions should be treated by reduction of deformity, when present, 
 and immobilization for about four weeks. 
 
 Fig. .34.5. — "Chauffeur's fracture" of lower end of radius, caused by kick of handle 
 while cranking. Line of fracture emphasized in retouching skiagraph. Orthopaedic 
 Hospital. 
 
 Both Bones of the Forearm. — These fractures are frequent, either 
 from a fall on the hand, or from direct violence. The forearm is 
 the most frequent site of green-stick fractures; the deformity usually 
 is very apparent (Fig. 34(j), and the treatment consists in reducing 
 this, which usually involves making the fracture complete ; but as this 
 frequently is accomplished without much rupture of the periosteum, 
 there is little or no tendency for the fragments to be displaced 
 subsequently. The forearm is dressed as in complete fractures. In 
 these the radius usuallv is broken a little higher than the ulna, and one 
 
356 
 
 FRACTURES 
 
 or both bones may be comminuted (Figs. 347 and 34S). The diagnosis 
 is easy, ovs'ing to the extreme mobility. Reduction should be attempted 
 
 Fig. 346. — Green-stick fracture of both bones of forearm one month after injun,- which 
 was untreated. Reduced under anesthetic. Children's Hospital. 
 
 by fully supinating the forearm, and making extension and counter- 
 extension so as to overcome any overlapping. Correct replacement 
 
 Figs. 3-17 and 348. — Skiagraphs of comminuted fracture of both bones of forearm ; 
 delayed union at end of ten weeks. Patient, aged fifty-three years, then returned to 
 work as blacksmith, and two months later union-was firm. Episcopal Hospital. 
 
 of the ulnar fracture usually can be determined clinically, as this 
 bone is subcutaneous; Init the radius is buried among so many muscles 
 
FRACTCRES OF THE FOREARM 
 
 357 
 
 tliat a skia^'rapli frrf|iUMitly is necessary to ascertain the position 
 of the t'ra'Mnents if the fracture is al)()ve the middle of the hone. 
 
 ^Fk;. 349.— Dressing for fracture of both bones of forearm. Padding oniitt(;d. Note 
 length of splints. Forearm in full supination. Episcopal Hospital. 
 
 Fig. .350. — Skiagraph of fracture of 
 both bones of forearm, before reduc- 
 tion; lateral view, in mid-pronation. 
 Age nine years. (See Figs. 351, 352, 
 353.) Episcopal Hospital. 
 
 Fig. 351. — Skiagraph of fracture of both 
 bones of forearm, before reduction; antero- 
 posterior view. (See Fig. 350.) Episcopal 
 Hospital. 
 
 The forearm is then dressed in fvll supinatwn between two straight 
 splints, that on the flexor surface extending from the bend of the 
 
3oS 
 
 FRACTURES 
 
 elbow to the tips of the fintrers, while the dorsal splint extends from 
 the olecranon to the wrist (Fig. 349). These splints should be a little 
 wider than the forearm, so as to prevent crowding the bones together 
 laterally, and they should be smoothly but thickly padded. Apply 
 the spliiits with the elbow flexed to a right angle, and make sure that 
 the palmar splint does not compress the veins in the bend of the 
 elbow. A longitudinal pad placed between the bones, in the eft'ort 
 
 Fig. 352. — Skiagraph of fracture of both 
 bones of forearm after reduction. Antero- 
 po.sterior view, in full supination. Same case 
 as Figs. 350 and 351. Episcopal Hospital. 
 
 Fig. 353. — Skiagraph of fracture of 
 both bones of forearm after "reduc- 
 tion." Recovery with perfect func- 
 tions and no palpable deformity. Epis- 
 copal Hospital. 
 
 to wedge them apart is not only useless but harmful. Extra com- 
 presses, however, may well be placed over any of the fragments that 
 tend to project. The splints are then strapped snugly around the 
 forearm and held securely in place by a roller bandage. A large 
 "handkerchief" or "triangular" sling is applied, and the forearm 
 carried against the chest, but always in full supination. I urge the 
 employment of this position not only because supination is the most 
 difficult part of rotation to regain, and because the upper fragment 
 
FRACTURES OF THE ('ARFVS 
 
 359 
 
 of the radius usually is kept in supination by the biceps, but because 
 I lia\e found, if the forearm is ilressed in niid-pronation, as is com- 
 monly ad\iscd now, that the fraj^ments saj^ by the force of gravity, 
 and the j)aticnt recovers not only with lost sui)ination, but with 
 angular deformity of both bones toward the ulnar side. If attempt 
 is made to correct this deformity by adjusting a coa{)tation splint 
 over the angular projection of the ulna, this may be overcome, Init 
 the surgeon will succeed merely in forcing the ulna nearer the radius, 
 which camiot be influenced by such an appliance, and the disability 
 as regards rotation will be increased. It often is exceedingly difficult 
 to keep these fractures even approximately reduced during the 
 first week; but usually a little better position can be secured at each 
 
 Fig. 3.54. — .Skiagraph of fracture of carpal scaphoid. Compare with normal 
 wrist in Fig. 3.5.5. Episcopal Hospital. 
 
 dressing, and when the ends of the bones begin to become sticky, 
 during the second week, it will be found that deformity daily becomes 
 less, and what looked at first like a hopeless case, will result in a very 
 useful arm, and one with slight or no visible deformity. Skiagraphs 
 are valuable and interesting, but I advise the inexperienced not to 
 be terrified by the appearance of the bones in a skiagraph into think- 
 ing that only operative treatment can give his patient a good result. 
 If he uses the eyes in the ends of his fingers, he will secure by con- 
 servative means quite as good, and in many cases a much better 
 result than by operation, and in a shorter time (Figs. 350, 351, 352, 
 and 353). 
 
 Carpus. — Of these fractures, that of the scaphoid is least unusual, 
 resulting usually from a fall on the thenar eminence; the diagnosis 
 
360 
 
 FRACTURES 
 
 is made from tenderness in the "anatomical snuffbox," sometimes 
 l)y dorsal displacement of one of the fragments, and effusion in the 
 
 Fig. 355. — Skiagraph of normal wri.st. Compare with Fig. u.Ji. Episcopal 
 
 Hospital. 
 
 radio-carpal joint. Confirmation by a skiagraph is advisable (Figs. 
 354 and 355). Treatment consists in excision of an irreducible frag- 
 
 FiG. 356. — Dressing for fracture of metacarpals. Hand bandaged over a roller. 
 Episcopal Hospital. 
 
 ment, and in immobilization on a palmar splint for three or four weeks 
 for those cases without deformity. 
 
FRACTURES OF THE METACARPUS 
 
 361 
 
 Metacarpus. Fractiirrs of the metacarpals result usually from 
 (lirrct violence (pri/c-fiKlitinj,', etc.); the (lisi)laeement is au^nilar, 
 toward the extensor surface, and may he difhcult to keep reduced. 
 
 Fig. .357. — Fracture of base of thumb metacarpal. Episcopal Hospital. 
 
 The hand may be dressed on a palmar splint, the palm being well 
 padded; or may be bandaged over a firm roller, the tension on the 
 
 Fig. 358. — Dressing for fracture of the phalanges. Episcopal Hospital. 
 
 extensor tendons preventing deformity (Figs. 350) . Fracture of the base 
 of the tJmmb metacarpal (Bennett, 1886), may resemble a subluxation 
 of that bone (Fig. 357). 
 
362 FRACTURES 
 
 Phalanges. — Fractures of these usually are caused by direct 
 violence, often being compound and requiring amputation. Simple 
 fractures are dressed on antero-posterior splints (Fig. 358) for about 
 three weeks. If angular deformity toward the flexor surface persists, 
 due to the pull of the interossei, Stimson (1907j advises dressing 
 the fingers in flexion over a roller bandage. 
 
 FRACTURES OF THE LOWER EXTREMITY. 
 
 Femur. — This is the most serious fracture of the extremities that a 
 patient can suffer, but fortunately it is less serious in children, in 
 whom it is more frequent, than in adults. In adults fractures of 
 the leg are much more frequent than in children. The fractures of 
 the femur may be grouped into those of the upper end, those of the 
 shaft, and those of the lower end. 
 
 Fig. 3.59. — Fracture of neck of femur close to its head. Episcopal Hospital. 
 
 Fractures of the Upper End of the Femur. — Fractures of the neck 
 of the femur ("fracture of the hip") are more common in adults, 
 especially those past sixty-five years of age, than in children. The 
 trauma in the aged often is trivial as their bones are more brittle; 
 some cases are caused by a mere twist of the leg, catching it in a 
 
FHACTUJiES OF THE FEMUR 
 
 363 
 
 fold of tlu' cariH't, on an uneven paving' stone, etc., or by sitting down 
 suddenly. Such injuries usuall\ produce a fracture of the neck close to 
 the head (intracapsular), and seldom are iui[)acted (Fig. iiolJ). Falls 
 on the great trochanter, especially in ])atients under seventy years of 
 age, are more apt to result in an impacted fracture close to the trochan- 
 ter (Fig. ;)()()), which is at least partly extracapsular. In children, 
 also, fractures of the neck of the femur usually are impacted, or 
 partial; or an epiphyseal separation of the head may occur. In 
 impacted fractures, the impaction occurs chiefly at the expense of 
 the posterior i)art of the neck, the shaft of the femur being rotated 
 outward as the posterior margins of the fragments are driven together. 
 
 Fig. 360. — Impacted fracture at base of neck of femur. Age sixty-five years. 
 Note also coxa vara. Episcopal Hospital. 
 
 Symptoms. — ]\Iuscular spasm is prominent, and this, with local- 
 ized pain and tenderness, sometimes are alone sufficient to warrant 
 the diagnosis in the aged. In unimpacted fractures the patient 
 usually is unable to raise the limb from the bed; deformity is char- 
 acteristic, consisting in eversion of the lower extremity, the fibular 
 side of the foot lying on the bed; and there is moderate shortening 
 (2 to 4 cm.), which frequently increases during the second day. In 
 
364 
 
 FRACTURES 
 
 impacted fractures the shortening may not exceed 1 cm. Normally 
 when the thigh is flexed the great trochanter lies on a line drawn 
 from the anterior superior spine of the ilium to the tuber ischii 
 (Xelatons line, 1847); but when there is fracture of the neck of the 
 femur the muscles (ilio-psoas, adductors, hamstrings, glutei) passing 
 from the pelvis to the shaft pull the lower fragment up, so that the 
 trochanter lies above this line, and approaches or even ascends above 
 a plumb line dropped from the anterior superior spine when the patient 
 is lying supine i Bryanfs line, lS79j; the relation of the trochanter to 
 Xelaton's and Bryant's lines on the two sides should be compared (Figs. 
 361 and 362). The trochanter is less prominent on the injured side 
 owing to the loss of support from the neck of the bone, and by placing 
 the tips of the fingers between the trochanter and iliac crest it will 
 be found that the fascia lata on the injured side is relaxed (Allis's 
 sign, 1877). Sometimes from the shortening a fold or wrinkle is 
 formed over the tendo patella, and can be smoothed out by making 
 
 Fig. 361. — Xelaton's line: passes from 
 anterior superior spine of ilium to tuber 
 ischii and crosses tip of great trochanter 
 of femur, when thigh is partly flexed. 
 
 Fig. 362. — Bryant's line, a plumb line 
 from anterior superior spine of ilium, 
 patient supine. Orthopaedic Hospital. 
 
 extension (Cleemann, 1876). In cases without impaction, mobility 
 is present: tliis may be detected by rotating the entire limb, when 
 it will be found to have a greater range of motion than the uninjured 
 limb; and by pushing upward and pulling downward in the axis 
 of the limb, the greater trochanter will be found to .slide up and 
 down on the pelvis. During these manoeuvres crepitus usually is 
 elicited. By palpating the trochanter as the limb is rotated, it will 
 be found to rotate in the arc of a smaller circle than the trochanter 
 on the uninjured side; this is because the centre of motion is trans- 
 ferred from the acetabulum to the seat of fracture. Usually there is 
 an abnormal fulness over the head of the femur (just below Poupart's 
 ligament, beneath or immediately external to the femoral artery) 
 owing to effusion in the joint and the external rotation of the outer 
 fragment. 
 
 Diagnosis rarely is difficult in the adult, attention being paid 
 to the history of injury, even if slight, and to the cardinal physical 
 signs, shortening, eversion, and crepitus. In cases with impaction. 
 
FRACTURES OF THE FEMl'R 3Go 
 
 wliere in()l)ility and crepitus are al)sont. and wlicrc evcrsioii and 
 sli()rt(Miin<!; are sliij;lit, the diaifiiosis is less certain; hut tiie cautious 
 surjieou will treat all suspected injuries of the hip in the aged as if 
 they were fractures until the contrary is proved. The impaction 
 may he slight, and is apt to })e released spontaneously. A skiagraph is 
 very useful in such cases, and as well in children, in whom green-stick 
 fracture, epiphyseal separation, or fracture with impaction, are the 
 usual lesions. PVequently the true nature of the case is not recognized 
 in children, and the surgeon sees the patient first when traumatic 
 cu.ra vara (p. i)i'3) has developed. 
 
 Prognosis. — In the aged, death occurs from shock, pneumonia, 
 l)ed-sores, exhaustion, etc., in ahout one out of four cases during 
 the first year after injury; in those who recover, a useful limb results 
 in ahout GO per cent, of cases; nearly all of these will have a limp 
 and slight eversion (Ashhurst and Newell, 1908). In children there 
 is little disability though marked degrees of coxa vara may require 
 subsequent treatment. 
 
 Treatment. — In the aged, constitutional treatment often is more 
 important than the local; these patients should not he kept in bed 
 after the first shock of the accident and the acutest symptoms have 
 subsided, unless the}' continue to improve. Get them up in a chair 
 a few hours each day so soon as they seem to be losing ground. Watch 
 for and guard against hypostatic congestion of the lungs and bed- 
 sores. Keep the bowels open and the kidneys active. Stimulate 
 the appetite. 
 
 The usual teaching is not to disturb an impaction if one is present; 
 and a very good rule it is in almost all cases; hut in children this does 
 not hold good if there is deformity, and in such cases even in young 
 adults (even up to forty-eight years), it is a question whether a more 
 useful limb might not be secured by breaking up the impaction 
 and dressing the limb in extreme abduction as described below. 
 Impaction is rare except in fractures near the trochanters, and non- 
 union would not be apt to occur if the impaction were reduced in 
 vigorous adults. But in aged persons, or speaking generally, in those 
 past sixty years, it is far better to let the fracture stay impacted, 
 even if there is deformity, since it is better to have them walking 
 about with a limp and shortening and eversion, than to have them 
 dependent on crutches or even a cane, as is almost always the case 
 if non-union is present. Cotton suggested in (1910) producing arti- 
 ficial impaction in recent fractures by hammering on the trochanter 
 with a mallet, and has practised this method with success in a 
 number of cases. 
 
 Unimpacted fractures may be reduced by flexing the thigh on 
 the pelvis to a right angle (to relax the iliopsoas which may press 
 the capsule between the fragments), then making vertical traction 
 upward on the thigh, and finally bringing the thigh down to the plane 
 of the bed in moderate internal rotation and abduction as great as 
 possible. This last manoeuvre makes the anterior portion of the 
 
366 
 
 FRACTURES 
 
 capsule tense, and wedges the outer fragment against the detached 
 head lying loose in the acetabulum by causing the great trochanter 
 to impinge on the posterior lip of the acetabulum, and by keeping 
 
 the iliopsoas tense across the 
 anterior part of the joint. Whit- 
 man, who since 1904 has ad- 
 vocated the abduction treatment 
 of fractures of the femoral neck, 
 encases the entire lower extrem- 
 ity and pelvis in plaster of Paris 
 (Fig. oOo) ; but this is not always 
 well borne by old people, in 
 whom it often is better to use 
 the ordinary Buck's extension 
 apparatus (Fig. 364), using 
 enough weight (8 to 12 pounds) 
 to prevent muscular spasm. The 
 position of abduction may be 
 encouraged by fastening the 
 pelvis to the opposite side of 
 the bed. However, it is very 
 difficult to maintain sufficient 
 abduction without a gypsum 
 splint, and in all adult patients I 
 prefer the method of lateral and 
 longitudiiml traction, which in- 
 variably has given me better 
 results. This was described accurately in 1869 by Phillips, was taught 
 for many years by Maxwell, and has been revived, systematized, and 
 
 
 
 Fig. 363. — Abduction cast for separation 
 of epiphysis of head of femur; age fourteen 
 years. Cast has been cut off foot recently 
 to facilitate walking. Episcopal Hospital. 
 
 Fig. 364. — Applying Buck's adhesive plaster extension apparatus for fracture of femur. 
 
 Orthopaedic Hospital. 
 
 popularized, by Rvith (1899). The fracture is reduced as described 
 above, and in addition to the longitudinal extension lateral traction 
 also is made on the upper part of the thigh. The longitudinal 
 
FRACTURES OF THE FEMUR 
 
 367 
 
 traction sliould bo stronj;; enoiiffli to overcome sliorteniiig, and al)out 
 two-thirds as niiicli \veitj;lit should l)e used in hiterai traction (Fi^- •>•>•"))• 
 The lateral traction, which should draw the femur slij^ditly away 
 
 Fig. 365. — Longitudinal and lateral traction for fracture of neck of femur. No(n 
 also use of Volkmann's sliding foot splint to prevent rotation of limb. Episcopal 
 Hospital. 
 
 Fig. 366. — Fracture through trochanter.s (if femur; rare and atypical line of fracture. 
 
 Episcopal Hospital. 
 
368 
 
 FRACTURES 
 
 from the plane of the bed as well as laterally, overcomes eversion 
 and keeps the capsule of the hip-joint tense, preventing it from 
 falling in between the fragments. Every two or three days the 
 longitudinal traction should be substituted by traction with the 
 hands upon the thigh, and the knee should be flexed gently through 
 about 30 degrees to prevent stiffness. Union is good at the end of 
 four weeks. Ruth found in 1907 that among a total of 72 cases 
 treated by this method there had been no failure of union in patients 
 under eighty years, no failure to secure a useful limb under seventy 
 years of age, and in those past eighty years of age success was obtained 
 in over 60 per cent, of cases. Impacted fractures are treated in the 
 same way, but less weight is required. 
 
 Fractures through the trochanters of the femur are not very rare, 
 usually are due to great direct violence, and often are impacted. 
 
 Three grades of this injury may be 
 recognized (Ashhurst, 1913): the first is 
 little more than an impacted fracture 
 at the base of the neck; in the next, the 
 neck penetrates the trochanteric region 
 further, and a splitting fracture occurs; 
 and in the severest grade the trochanteric 
 region is entirely shattered. A linear 
 fracture between the level of the trochan- 
 ters is quite rare (Fig. 366). In most 
 cases the lesser trochanter is fractured 
 (Fig. 367). Binet and Hamant (1911) 
 have collected eight cases of isolated frac- 
 ture of the lesser trochanter. Isolated 
 fracture of the great trochanter occurs, and 
 may require periosteal suture to maintain 
 reduction. 
 
 Fractures of the Shaft of the Femur. — 
 These are much more common in children 
 and young adults than in old people, 
 and usually are due to direct violence. 
 There are three main types: (1) Fracture 
 heloiv the trochanters. The upper fragment is flexed by the iliopsoas; 
 and rotated outward by the gluteus maximus and the short external 
 rotators. The lower end of the upper fragment often is felt as a sharp 
 projection in Scarpa's triangle; while the lower fragment is drawn 
 upward and inward by the adductors (Fig. 368). The leg rolls out- 
 ward from its own weight, and shortening is marked. Crepitus and 
 abnormal mobility are easily detected. (2) Fracture of the middle of the 
 shaft, often oblique (Fig. 272), is attended by more shortening than 
 any fracture in the body, sometimes as much as 12 cm. (five inches); 
 the leg rolls outward, there is flail-like motion and marked crepitus 
 at the seat of fracture; the lower fragment is drawn up and in by the 
 adductors and hamstrings, and the upper fragment projects anteriorly 
 
 Fig. 367. — A common type of 
 fracture through the trochanters: 
 fracture at base of neck of femur 
 (impacted) ; with separation of 
 lesser trochanter. Age forty-five 
 years. Episcopal Hospital. 
 
FliACTUliES OF THE FEMUR 
 
 369 
 
 (Fi^. 'M\\)). (o) SiiprdroiKJi/htrfrdcturcs are cliaractori/od ])y i)()sterior 
 (lisi)la(riiu'iit of tlio lower tragmeiit wliieh is kept flexed at the knee 
 by the ^astroeiiemiiis (Fig. -iTl); and hy anterior projeetion of the 
 upper fragment, wiiieh may be embedded in the reetus musele. The 
 diagnosis of these ^■arious types of fraetnre of the shaft is not difficult, 
 since the displacement is fairly constant, and if deformity is great the 
 ends of the fragnuMits ustiall> can i)e ])alpate(l even in \ery nuiseular 
 limbs. 
 
 Fig. 368. — Fracture of femur below trochanters. Episcopal Hospital. 
 
 Prognosift. — The general mortality is about 15 per cent.; 90 per cent, 
 of those who recover under conservative treatment secure entirely 
 useful limbs, but about one out of three of these will have a limp, 
 and only about one patient out of four will have no shortening (Ash- 
 hurst and Newell, 1908). Though many surgeons urge the operative 
 treatment of recent fractures of the femur as a routine, I am not 
 aw^are that they have published figures demonstrating even as good 
 results as the above. 
 
 Treatment. — Reduction of the fracture is difficult, but probably 
 could be more often obtained if the patient was anesthetized. Weight 
 24 
 
370 
 
 FRACTURES 
 
 extension should be applied in sufficient amount to overcome shorten- 
 ing. Ochsner has found that if the adhesive plaster is carried up to 
 the groin, irrespective of the height of the fracture, weight extension 
 is much more efficacious. I'he full amount of weight necessary 
 should be applied during the first day or two after the accident, 
 since shortening becomes more difficult to overcome the longer it lasts. 
 By raising the foot of the bed from four to six inches, counter-exten- 
 sion is provided by the weight of the patient's body. If necessary 
 
 Fig. 369. — Pkiapraph of traiisvcrso 
 fracture of shaft of femur. Best po!<i- 
 tiou ol)tainal)le after etherization and 
 attempts at reduetion with extension 
 bv ooinpound pulley. Femur plated. 
 (See Fig. 370.) Ago twenty-three 
 years. Episcopal Hospital. 
 
 Fig. 370. — Skiagraph of patient shown in 
 Fig. 309, three months after fracture of femur 
 was plated. Excellent result, with scarcely 
 appreciaiiie limitation of motion. Episcopal 
 Hospital. 
 
 the patient is anesthetized (usually on the second day) and, short- 
 ening being overcome by the weights, the fragments are manipu- 
 lated into as accurate apposition as possible. Extension by means 
 of the compound pulley may be necessary in very muscular adults, 
 the extension being made by means of a clove hitch applied above the 
 knee (Fig. 372). Sometimes angulation of the fragments over the 
 
FRACTURES OF THE FEMUR 
 
 forearm will enable the surgeon to secure end-to-end apposition. 
 Absolute reposition rarely can be obtained, and is not necessary 
 to secure a useful limb. In 
 subtrochanteric fractures it may 
 be necessary to raise tiie lower 
 fragment on a double-inclined 
 plane, in order to ai)i)roximate 
 it to the upi)er (Fig. 37.')); and 
 in supracondylar fractures it 
 always is a(hisable to flex the 
 knee (rarely to divide the tendo 
 Achillis) so as to relax the gas- 
 trocnemius muscle. In fracture 
 of the middle of the shaft the 
 thigh is dressed in the extended 
 position, and the seat of fracture 
 always should be supported by 
 coaptation splints. Rotation 
 outward of the lower fragment 
 is prevented by the use of \'olk- 
 mann's sliding splint (1882) or 
 similar device (Fig. 3()5). A 
 long external splint (Liston, 
 1837), well padded, extending 
 from the axilla to below the 
 foot, and bandaged firmly to 
 the entire lower extremity and 
 pelvis, will prevent outward 
 angulation of the fracture; and 
 
 the use of a shot bag will over- ^ig. 371.-Skiagraph of fracture above 
 
 come anterior displacement. In pond^ Ics of femur. Lower fragment drawn 
 
 I'll TT -li ' !• j./io/'M\ baelcward by aetion of gastrocnemius. Epis- 
 
 children, Hamilton ssplmt( 1850) copal Hospital. 
 
 Fig. 372. — Clove hitch and compound pulley for reduction of fractures of the femur 
 under anesthesia. Counter-extension by a sheet tied to the head of the bed. Episcopal 
 Hospital. 
 
372 
 
 FRACTURES 
 
 facilitates moving the patient, as it fixes both lower extremities by 
 long external splints fastened together by a cross-bar below the feet, 
 through which passes the cord carrying the weight extension. Im- 
 mobilization in adults should be continued for six to eight weeks, 
 but after the first four weeks very light massage is permissible, 
 above and below the fracture. Weight-bearing should not be at- 
 tempted for eight or ten weeks after the injury — in general, not until 
 four weeks after union seems solid, as subsequent shortening with 
 angular deformity is a sad consequence of too early efi'orts to walk. 
 In very young children weight-bearing may be resumed in six or seven 
 weeks. 
 
 Fig. 373- — Double inclined plane, with weight extension for fracture of femur 
 below the lesser trochanter. Episcopal Hospital. 
 
 Fractures of the Lower End of the Femur. — Epiphyseal separation 
 occurs oftenest from six to ten years of age, usually from hyper- 
 extension or a twisting injury, as from having the leg caught in a 
 revolving wheel. The epiphysis usually is displaced forward (Fig. 
 374). Reduction may be difficult, and is best maintained by dressing 
 the knee in flexion. Fracture of one or other condyle, usually the 
 external, is more frequent in children than adults, and occurs mostly 
 from direct violence. There is mobility of the fragment, and lateral 
 mobility in the knee, in addition to crepitus, localized pain, etc. 
 Effusion, perhaps bloody, often occurs into the joint. Treatment 
 consists in immobilization with weight-extension or plaster cast, 
 in good position, for four or five weeks. Use of the limb should be 
 gradually resumed. 
 
 Patella. — If these fractures occur from direct violence there may 
 be comminution, but there seldom is much separation of the frag- 
 ments unless the lateral expansions of the quadriceps tendon are 
 ruptured; in fracture from muscular action, however, which is the 
 
i'ir\cTi'ia<:s of v///-; I'atklla 
 
 373 
 
 usual loriu, this librous cxpuiisiou is 
 takes place by sudden flexion of tlie k 
 l)reaks the patella o\(t the condyh's 
 as an o\-er-h(Mit U'\'er. The hone 
 nsuahy <fi\-es way more or less 
 trans\-ersely, the lower frafjnicnt 
 l)ein<; smaller. 
 
 Diagnosis. - l)iaji;nosis is easy, 
 owinu,- to separation between the 
 trajjnu'nts, free mobility, and crepi- 
 tus. If the quadriceps expansion is 
 not torn, the j)atient may still be 
 able to walk; usually he is entirely 
 disabled. I have seen, however, 
 two cases of subperiosteal fracture, 
 denionstratefl by skia^raplis, in 
 which there was no disability. 
 
 Treatment. — Treatment in most 
 cases is operative, as it is difficult 
 to secure good apposition without 
 suture of the fragments. But in the 
 aged, or those with visceral disease, 
 operation is much more of a risk, 
 and conservative treatment may se- 
 cure a very useful leg. The limb is 
 dressed on an inclined plane (Fig. 
 375), thus relaxing the quadriceps 
 muscle, and the fragments are ap- 
 proximated by straps of adhesive 
 plaster, much as in the case of frac- 
 tured olecranon; the plaster should 
 be readjusted every couple days to 
 
 widely torn, as the fracture 
 nee, and the tense quadriceps 
 
 Fig. 374. — Separation of lower epi- 
 physis of femur. Reduced under ether 
 and knee dressed in flexion on double 
 inclined plane. Dr. H. C". Deaver's 
 
 ciise. Episcopal Hospital. 
 
 Fig. 375. — Fracture of patella, dressed un inclined plane. Episcopal Hospital 
 
374 
 
 FRACrrRES 
 
 keep tlie fraf^ments as dose together as possible, and to avoid everting 
 tliem. 'J'his dressing is eontinufd for six weeks. Even if onlv fif>rous 
 
 Fio. 376.— Fracture of patella with wide separation of fraj^ments, showing power of full 
 extension six years after injury. No operation was done. Episcopal Hospital. 
 
 union results, and if after getting about the bond of union stretches, as 
 it frequently does, the power of extension of the knee may f>e retained 
 
 Fig. .'i77. — ltn<:ynr<: of j^at'-lla \,ii'ti'- '-(/'/.ition. Age twenty-eight years. 
 Episcopal Hospital. 
 
 (Tig. 370j; but in almost all cases there will be slight limp, and some 
 disability in gc>irig up stairs. Ojjeration is best done between the fifth 
 
I'liACrVUKH OF Till': IWTKLLA 
 
 375 
 
 iiiid tent li (lays jit'lcr iiijiifv ; cjirlicr iii(cr\ ciil imi ^(»Ill(•t iiiics is lollowcd 
 l).\ iiilcct ion, <-iii(l inrcctioii in w kiu'c-jointor this kind nsniilly r('(|iiir('S 
 iinipiitiitidii, ;iiid may rcsiiM in the pjiticiit's dcMlli. Tlic inortidily 
 ot" ojMTJition ex (Ml inidcr the l>rst conditions ni;iy rc;icli I |)(r cent. 
 (Iv (1. Alexander, Mill). The slrielest aseptic teehni(|ne is inipeni- 
 tive. A seniihuiar llap is turned (h)\vM or up, ex|)osin^' the seat of 
 fracture. The knee-joint is widely o])ene(l, and clots are removed 
 by forceps or sponuini;' with moist \i,\\\\/.v. Any frinjics of the (piadri- 
 cops aj)oueurosis turned down hetweeu the fra^nncnls are everted, 
 
 Fig. 378. — •Fracfurc of piitdl.-i riftcr siidirc willi r'litoiiiic cattiut. I'lpi.scdpal Hospital. 
 
 and two holes are drilled in each fra^ineiit, from the superficial to 
 the fractured surface, not in\'adinjf the articular surface of the patella. 
 The fragments are then sutured with a mattress suture of heavy 
 chromic catgut or wire; the quadriceps expansion and capsule are 
 sutured with chromic gut; and the skin with interrupted silkworm 
 gut (Figs. 'Ml and 'MX). In some cases it is suflicient to suture the 
 fibrous tissues alone, without direct suture of the bone (Blake, Gibbon, 
 1904). If all oozing has been checked, and the skin is not sutured too 
 tightly, it is not necessary to drain the wound; otherwise a small drain 
 
376 
 
 FRACTURES 
 
 should be left for forty-eight hours. The limb is dressed on a posterior 
 splint, which may be removed in a few days and the limb laid on a 
 pillow, with the knee slightly flexed. Most surgeons now recommend 
 l)eginning very gentle passive motion four or five days after operation, 
 bv raising the knee a few inches from the pillow once daily. Xo 
 active motion should be allowed for at least two weeks, and not then 
 unless the bone has been sutured with wire. If wire has been used, 
 the fragments depend on it for their apposition and not on the newly 
 formed callus. True bony union seldom results, and if absorbable 
 bone sutures have been used, the knee should be supported by a 
 posterior gypsum splint, or light brace, to prevent excessive flexion, 
 for eight weeks or more after operation. With non-absorbable suture 
 the patient may begin to walk without support in three or four weeks. 
 If wire has been used it may require to be removed. Ilefracture is 
 not verv rare. 
 
 Fig. 379.- 
 
 ^kiag^aph of partial separation of upper epiphysis of tibia. 
 (Schlatter's disease.) Episcopal Hospital. 
 
 Tibia. — These fractures frequently are caused ])y direct violence, 
 except those of spiral type following twists of the foot, and those 
 of the internal malleolus accompanying fracture of the lower end of 
 
FRACTURES OF THE T/IilA 
 
 377 
 
 the fil)iila. The suhcutaneous position of tlie tibia, aiul the fact 
 that it sujiports the main weight of tlie body, render it mnch more 
 liahlc to i!ijiir\- than the fibula, fractures of tlie shaft of whicli rarely 
 occur except as secondary lesions in fractures of the tibia. The 
 fractures from direct violence often are compound or comminuted. 
 
 Fmcturcs of Ihc upper end of the tibia fretjuently run into the knee- 
 joint (Fig- -~^'). !•"<! s•^•novitis may result; as the fracture may be 
 
 subi)eriosteal or impacted, involve- 
 
 ment of the knee-joint with pain and 
 tenderness over the head of the tibia, 
 should make one suspect such a frac- 
 ture. ( 'omplete sepaniiion of the upper 
 epiphysis of the tibia is rare, but " start- 
 ing of the epiphysis," sometimes known 
 as Schlatter's disease (1903), is a not 
 infre(iuent accompaniment of sprains 
 of the knee in adolescents; the tibial 
 tubercle, which forms part of the 
 epiphysis, is partially lessened by the 
 pull of the tendo patella^, and peri- 
 osteal thickening results (Fig. 379). 
 Most cases resemble "sprain-frac- 
 tures" (p. 298), but in some the tibial 
 tubercle is broken loose and is pal- 
 pable as a distinct fragment. Treat- 
 ment consists in rest until acute 
 symptoms subside; immobilization of 
 the knee should be continued for 
 several weeks. 
 
 Fraetures of the shaft of the tibia gen- 
 erally are oblique, and deformity may 
 be great, owing to the pull of the calf 
 muscles on the foot which causes 
 shortening, and angular projection 
 forward of the upper fragment. If 
 this is pointed, as it usually is, there 
 is danger of its causing a slough in the 
 skin (Fig. 380). There also is a ten- 
 dency to external rotation of the upper 
 fragment from the weight of the thigh. 
 Owing to the deformity, mobility, and 
 crepitus, diacpiosis is easy. The fibula 
 very frequently is broken also. Treatment consists in reduction of the 
 deformity by extension, counter-extension, and manipulation; it may 
 be assisted by placing the leg in Pott's position (1771) — lying on 
 its fibular side with the knee flexed nearly to a right angle. Where 
 posterior displacement of the lower fragment is very persistent, it 
 may be advisable to divide the tendo Achillis. The leg may be put 
 
 Fig. 380. — Skiagraph of fracture 
 of both bones of leg; foot displaced 
 backward by contraction of calf 
 muscles; lower pointed end of upper 
 tibial fragment protruding subcu- 
 taneously on front of leg. Fracture 
 of fibula comminuted and typically 
 higher than that of tibia. Episcopal 
 Hospital. 
 
378 
 
 FRACTURES 
 
 up in plaster of Paris at once, in eases where the condition of tlie 
 soft parts will admit of this procedure, and in which reduction can 
 be surely maintained while the plaster is setting; in this case the 
 dressing must extend from the toes to above the knee, and it is very 
 important to keep the foot at a right angle with the leg. The gypsum 
 
 Fig. 381. — Loni; fiactiiro bux, fur fracture of hones of leij;. Xoto (lr\- dressing over 
 wound of compounil fracture of tibia and foot bandaged to fo(jt piece. Episcopal 
 Hospital. 
 
 case must be renewed at the end of a week or ten days, as subsidence 
 of the primary swelling will have rendered it loose and hence useless 
 in keeping the fragments in good position. In cases where the primary 
 swelling is great, with bullae, ecchymoses, etc., it is better to postpone 
 the application of a plaster of Paris dressing for a week or ten days, 
 
 Fig. 3S2. — Long fracture box for fracture of bones of leg, sides raised and fastened 
 around leg. Episcopal Hospital. 
 
 keeping the leg meantime in a fracture box (Figs. 3S1 and 382), 
 securely packed into a pillow which fills up all irregularities and keeps 
 the leg straight; a small shot-bag may be laid over the projecting 
 fragment. While in the fracture box great care must be exercised to 
 protect the heel and malleoli from pressure by "floating" the former 
 
FRACTURES OF THE FIBULA 
 
 379 
 
 on a compress placed under the tendo Aehillis. and hy suitably pad- 
 ding,' the malleoli; and the heel should he kept down against the foot- 
 piece of the fracture hox, to i)revent ccpiinus deformity. Rotatory dis- 
 placement of either the upper or lower frai,nncnt inust he piarded 
 against. Another very good dressing is the posterior wire frame of 
 Cabot, i^laced under tlie lower extremity from the gluteal crease to the 
 ends of the toes, the wire ])eing suitably padded, and the splint covered 
 with cotton cloth. The limb is then laid on this over folded sheets 
 or towels so applied as to equalize pressure and leave the heel free; 
 one or two lateral splints are then applied, and fastened to the frame 
 and each other b\- adhesive plaster or webbing straps with buckles. 
 
 Fig. 383.— Skiagrai)h of Pott's fracture of left leo 
 Episcopal Hospital. 
 
 A<i:(' forty-two years. 
 
 Fractures of the Fibula.— /^racf?/ re of the shaft of this bone is rare, 
 except when accompanied by fracture of the tibia, to which it usually 
 is secondary. In such cases the treatment described above for fracture 
 of the tibia is to be employed. Isolated fracture of the upper part 
 of the shaft of the fibula often results in delayed union or non-union, 
 as it is very difficult to secure apposition of the ends of fragments 
 buried in such a mass of muscular tissue. Fracture of the lower fifth 
 
380 
 
 FRACTURES 
 
 of the fibula is a very frequent injury, resulting from indirect violence, 
 the foot, as a rule, being turned violently outward (eversion fracture); 
 as the astragalus forces the external malleolus outward, the tibio- 
 fibular ligaments act as a fulcrum, so that the fibula is bent in against 
 the tibia above the attachment of these ligaments, and finally breaks 
 at this point, two or three inches above the ankle-joint; the internal 
 malleolus often is avulsed from the tibia, at the same time (Fig. 383); 
 and to this combined lesion the name of Potfs Fracture is given, it 
 having been studied carefully and graphically described by Pott 
 in 1771. A somewhat similar lesion mav result from inversion of 
 
 Fig. 384. — Skiagraph of fracture of lower fifth of fibula, internal malleolus and 
 posterior articular surface of tibia, with posterior dislocation of the foot. Episcopal 
 Hospital. 
 
 the foot, but then usually the fracture of the fibula detaches merely 
 the external malleolus, and the tibial fracture enters the ankle-joint. 
 Xo accurate description can be given of the lines of fracture in these 
 various injuries, as they vary greatly in different cases. Other lesions, 
 which may or may not be present, are rupture of the tibio-fibular 
 ligament, rupture of the internal lateral ligament of the ankle without 
 fracture of the internal malleolus, fracture of the external border of 
 the articulating surface of the tibia, separation of the lower tibial 
 epiphysis, or posterior dislocation of the ankle-joint (Fig. 384). 
 
 Sjrmptoms. — Symptoms of Pott's fracture are a well-marked and 
 characteristic deformity, consisting in eversion of the foot, and marked 
 
FRACTURES OF TIII'J FIBULA 
 
 381 
 
 prominriK'o of the internal malleolus or of the lower end of the tibia 
 when the malleolus is avulsecl; almost always there is a tendency 
 for the foot to slide backward, causing elongation of the heel and 
 prominence of the tibia anteriorly. As a rule, lateral mobility is 
 marked, and crepitus easily . detected. But since fracture in this 
 region occasionally exists without displacement, being subperiosteal 
 or imi)acte(l, the surgeon always should treat a suspected case as one 
 of fracture until this can be dis])roved by skiagraphy or otherwise. 
 
 Treatment. — Accurate reduction is im- 
 perative if a good result is to be obtained: 
 imperfect reduction in an antero-posterior 
 direction will limit (h^rsal flexion of the 
 ankle, and imperfect correction of the 
 eversion will render the patient liable to 
 develop static flat-foot, and will cause last- 
 ing disability in locomotion (Fig. 385). 
 Sometimes general anesthesia is necessary 
 to secure reduction. Grasping the heel 
 in one hand, and the leg in the other, the 
 surgeon brings the foot forward until the 
 astragalus bears its normal relation to the 
 tibia, and then supinates the foot, so as to 
 replace the internal malleolus and over- 
 come the internal bowing of the fibula. If 
 there is little reaction in the soft parts a 
 plaster of Paris dressing, from toes to knee, 
 may be applied at once, to be renewed in 
 a week or ten days. In most cases, how- 
 ever, it is safer to dress the leg tempor- 
 arily in a fracture box, with a pad below the external malleolus and one 
 above the internal malleolus to overcome eversion, and with careful 
 support to the heel, keeping this well down against the footboard so as to 
 
 Fig. 38.5. — Deformity follow- 
 ing unreduced Pott's fracture of 
 left foot, two months after in- 
 jury. Episcopal Hospital. 
 
 FiQ. 383. — Dupuytren's splint for Pott's fracture. Note pads along tibial surface 
 of leg, allowing inversion of foot. Episcopal Hospital. 
 
 prevent the development of a pointed-toe deformity; or the leg may 
 be dressed in Pott's position on a Dupuytren splint (1819) (Fig. 386). 
 Weight should not be borne on the foot for at least eight weeks. In 
 many cases, where reduction has been imperfect, stiffness and edema 
 may persist for some months, and may require massage, passive 
 motion, baking, etc., for their relief. 
 
382 
 
 FRACTURES 
 FRACTURES OF THE FOOT. 
 
 Fractures of the Tarsus usually result from direct \iolence or 
 falls on the feet, and often are impacted. Localized tenderness 
 
 Fiu. 3S7. — Impacted fracture of neck of right astragalus. Episcopal Hospital. 
 
 Fig. 388. — Skiagraph of fracture of calcaneum, comminuted and impacted. 
 Episcopal Hospital. 
 
FRACTURES OF TIIIC FOOT 
 
 383 
 
 following]: severe injury is the most valuahle symptom, since swelling; 
 oF the soft parts may ohseure deformity, and since mol)iiity and 
 crei)itus frecjuently are ahsent. ('orresjjondiiiif injuries often exist 
 in both feet, and two or more l)ones often are fractured in the 
 same foot. The a.stragaliift most frequently is broken through its 
 neek (Fig. 'AST; see also p. 414). Fractures of tlie caJcancinn are 
 more frequent, and often may l)e diagnosed clinically from the 
 
 Fig. .389. — Fracture pf second, third, fourth, and fifth metatarsal bones. Heavy 
 .stone fell on foot. Age twenty-three years. Episcopal Hospital. 
 
 flattening of the heel and prominence of the calcaneum below the 
 external malleolus; if the fracture detaches the posterior half this 
 may be considerably displaced upward by the tendo Achillis; more 
 often there is a general crush of the bone (Fig. 388) . These fractures 
 are best treated by immobilization in good position in plaster of Paris 
 for three or four weeks; but weight -bearing should not be allowed for 
 several months. Traumatic flat-foot should be corrected by moulding 
 the foot over the surgeon's knee or a sand pillow, as the plaster sets; 
 
384 
 
 FRACTURES 
 
 division of the tendo Achillis may be necessary; the eversion of the 
 heel should be corrected also. If impaction of the calcaneum with 
 deformity cannot be overcome without incision, it will be proper to 
 do osteotomy of the heel portion so as to restore the normal weight- 
 bearing surfaces. This has been done by Chutro (1909) as a secondary 
 operation. 
 
 Fig. 390. — Fracture of tuberosity of fifth metatarsal bone; patient had been treated 
 for "sprain of foot." Age twenty-three years. Episcopal Hospital. 
 
 Fractures of the Metatarsus. — The metatarsal bones usually are 
 fractured by direct violence, usually two or three at once (Figs. 389) . 
 Deformity is slight, but disability may be great. Diagnosis is based 
 on persistent localized tenderness usually with mobility, and some- 
 times crepitus. Fracture of the base of the fifth metatarsal bone (Fig. 
 390), or epiphyseal separation at this point, which is a less frequent 
 injury, sometimes occurs from direct injury in stepping on the outer 
 side of the foot. 
 
 Fractures of the Phalanges are rare, even from direct violence, 
 and then usually are compound and require amputation. 
 
CHAPTHR XIII. 
 INJURIES OF JOINTS. 
 
 Sprains and Contusions. — A sprain is an injury to the lijijamcntous 
 striK'turrs surroundin*;' a joint, caused by a wrench or a twist; there 
 may he a suhhixation or actual dislocation of the bones composinj^ 
 the joint, spontaneously reduced. Uoss and Stewart (H)ll), main- 
 tain that every sprain is a sprain-fracture, the lijijament giving way 
 at its bony attachment.^ Contusions are rarer than sprains, and 
 are due to direct injury, the blow being received over the joint or 
 being transferred to it through the bones; by the latter mechanism 
 may be ex])laincd fracture or displacement of intra-articular cartilages 
 (p. 412). The joints most often sprained are those of the foot, wrist, 
 shoulder, and elbow. 
 
 Symptoms. — The symptoms of the two conditions are those of 
 inflammation in general, with perhaps the added special symptoms 
 of synovitis (p. 4G3), thecitis (p. 279), or sprain-fracture (p. 298). 
 The joint assumes that position in which tension is least, the ankle 
 being in slight plantar flexion and adduction, the wrist in flexion, 
 etc. The swelling, heat, redness, etc., may appear in a few moments, 
 but if the joint is well supported {e. </., by a shoe), and its use is per- 
 sisted in, they may not manifest themselves until after support is 
 removed. In the foot the subastragalar joint is that most frequently 
 sprained, the lesion being referred to popularly as "sprained ankle"; 
 the normal range of its lateral motion is suddenly exceeded either 
 in abduction or adduction, with laceration or complete rupture of 
 the internal or external lateral ligaments at the ankle; and in some 
 cases there is a diastasis of the tibio-fibular joint. There commonly 
 is efTusion around both malleoli (Fig. 391). Distinction from fracture 
 usually is possible after careful examination, by excluding abnormal 
 mobility or localized tenderness of the bones around the affected 
 joint, the symptoms in sprains pointing to the soft structures as the 
 seat of lesion. 
 
 Prognosis. — The prognosis is good, though in some rheumatic 
 patients slight disability may persist for months; and in a few cases, 
 especially sprains of the shoulder, periarthritis may ensue (p. 4(3G). 
 
 Treatment. — When seen early, it is best to strap the ankle with 
 adhesive plaster (Fig. 392), applying a firm bandage over this. In 
 mild sprains, limited use of the joint may be allowed when thus sup- 
 ported, but in severe cases the foot should be elevated, and kept at 
 rest for several days. This strapping should be renewed every third 
 
 1 By a "strain" usually is understood a sprain of slight degree, in which the 
 tendinous rather than the ligamentous structures are injured. 
 25 
 
38G 
 
 INJURIES OF JOINTS 
 
 or fourth day, and may well be continued until function of the 
 joint can be resumed. In cases not seen until marked swellin*; has 
 developed, it is safer to treat the joint with anodyne or evaporating 
 lotions until tenderness and swelling begin to al)ate. Sprains of the 
 joints of the upper extremity may be dressed with ichthyol or 
 belladonna and mercury ointment, and the limb carried in a sling. 
 Absolute immobilization (plaster of Paris, etc.) rarely is advisable, 
 as tending to promote stiffness by interference with the circulation 
 of blood and lymph. In later stages much benefit is derived from 
 alternate hot and cold douches, massage, and gentle j)assive motion. 
 
 Fig. 391. — Sprained right, ankle (recent 
 accident). Episcopal Hospital. 
 
 Fig. 392. — Adhesive jihister .strapping for 
 ankle. Episcopal Hospital. 
 
 Wounds of Joints. — Open wounds of joints usually are very serious 
 lesions, since joints are very susceptible to infection. They may be 
 incised, lacerated, punctured, etc. Gunshot wounds of joints have 
 been considered in Chapter VII. 
 
 Diagnosis. — The diagnosis usually can be made by noting the 
 situation and depth of the wound, or by observing the escape of 
 synovial fluid, and the increase in its flow on manipulation or pressure 
 of the joint; under no circumstances should a joint wound be probed 
 with finger or instrument until all proper aseptic preparations have 
 been made. 
 
 Prognosis. — The prognosis depends on the joint injured, on the 
 nature of the injury, on the constitutional state of the patient, and 
 on the treatment employed. Except the vertebral joints, the knee 
 is the most dangerous joint in the body, but no joint wound can be 
 regarded as trivial: even those of the phalanges may require ampu- 
 tation, or at least result in ankylosis. Infection is the great danger, 
 and even supposedly aseptic operations occasionally terminate 
 
DlSmCATIONS 387 
 
 fatally when the knee is involved (p. 375). If proper treatment is 
 not undertaken promptly, pyarthrosis may result, followed by septi- 
 cemia and death, in spite of all the resources of surgery. 
 
 Treatment. — If seen before these (■omj)lications have arisen, the 
 wound should be packed with sterile gauze, and the limb surrounding 
 it prepared as for an aseptic operation; then any foreign bodies 
 remaining in the wound (cinders, clothing, glass, needle, etc.), should 
 be extracted, enlarging the wound if necessary, and evacuating 
 blood and clots from the interior of the joint; this should then be 
 gently irrigated (not sponged) with warm saline solution, and sutured 
 with provision for drainage. The joint is then immobilized by splint 
 or plaster of Paris, elevated, and surrounded by ice bags. In the case 
 of large joints weight-extension should be applied. Constitutional 
 treatment (purge, diuretic, sedative) should not be neglected. If the 
 joint does well, as shown by the absence of pain and fever, the drain 
 may be removed on the second day, and immobilization continued for 
 one or two weeks, when function should be very gradually resumed. 
 If the signs of infection arise (pain, fever, leukocytosis), indicating 
 the development of septic arthritis, the dressing must be removed 
 promptly, and better drainage instituted; this may be accomplished 
 by a counter-opening, or by numerous openings, with saline irrigation 
 once or twice daily, or in desperate cases by wide incision of the 
 joint (in the knee by dividing the tendo patellae and acutely flexing 
 the knee — Dudley Allen, 1906), and stuflSng the synovial cavity with 
 gauze. One thorough application to the opened joint of a strong, 
 hot antiseptic often will check the infection, usually with ankylosis 
 as a result; but the use of weaker solutions by irrigation is of doubtful 
 value. But if septicemic symptoms continue in spite of this heroic 
 treatment, the surgeon has only two resources left: these are excision 
 and amputation. In the upper extremity the former usually is 
 successful, as it sometimes is in the ankle-joint; but for the knee-joint 
 amputation usually is required, and, of course, should be resorted 
 to in the case of other joints, where excision has failed. Nor should 
 these radical operations be postponed too long, as when adopted 
 late in the disease even they may fail to save the patient's life. 
 
 Hemarthrosis. — Hemarthrosis may follow subcutaneous wounds 
 of joints, especially gunshot; in such cases it presents no special 
 interest, the symptoms being those of acute synovitis (p. 463). 
 But it may follow slight contusion in cases of hemophilia, and in 
 such patients may be a very serious malady. Under no circumstances 
 should such a joint be opened for exploration or drainage. It should 
 be put at rest, ice should be applied, and the hemophilia treated 
 as already advised (p. 227). 
 
 DISLOCATIONS. 
 
 Dislocation or luxation of a joint is a condition in which the articular 
 surfaces of the bones forming the joint are no longer in contact. 
 
388 INJURIES OF JOINTS 
 
 Dislocations, however, may be complete or incomplete {subluxation), 
 the articular surfaces in the latter form retaining a partial contact 
 with each other. It is usual to classify dislocations as traumatic, 
 congenital, and spontaneous or pathological: traumatic dislocations are 
 those resulting from the application of force; congenital dislocations 
 are those present at birth; and spontaneous or pathological dislocations 
 are those due to malformation of the joint surfaces from disease, 
 or to laxness of the periarticular structures. Dislocations may be 
 simple, compound, or complicated, these terms having the same sig- 
 nificance as when applied to fractures; they may be recent or old, 
 terms of relative meaning, and which sufficiently explain themselves; 
 and they may be primitive, when the displaced bone remains where 
 originally placed by the injury, or consecutive, when it assumes another 
 position owing to manipulations by bystanders, the surgeon, etc. 
 The direction of the dislocation is described as it regards the distal 
 bone or bones forming the joint: thus posterior dislocation of the 
 elbow means that the forearm (not the humerus) is displaced back- 
 ward ; but there are a few exceptions to this rule, which will be noted 
 later. 
 
 In the present chapter only traumatic dislfK-ations are considered, 
 pathological dislocations being discussed with diseases of the joints, 
 in Chapter XV, and congenital dislocations in connection with 
 orthopedic surgery, in Chapter XVI. 
 
 Causes. — As in the case of fractures, the mule sex and active adult 
 life act as predisposing causes of luxation. Certain joints are dis- 
 located much more commonly than others: the shoulder contributes 
 about 50 per cent, of all dislocations, while the elbow, the clavicle, 
 and the phalanges contribute only about 5 to 10 per cent, each; the 
 hip, ankle, and lower jaw contribute from 3 to 5 per cent, each; while 
 the wrist, knee, etc., are very rarely dislocated. 
 
 Dislocations are caused much more often by indirect than direct 
 violence. Usually the motion of the joint is forced beyond its normal 
 limit, the distal bone impinging against a fulcrum formed by a neigh- 
 Ijoring bone; the capsular ligament is thus ruptured at its weakest 
 point, and the head of the dislocated bone is forced through this 
 opening either by continuation of the original force, or rarely by 
 secondary muscular contraction. It thus happens that in each 
 joint there is a more or less typical primitive dislocation, because the 
 head of the bone habitually emerges at the weakest part of the capsule 
 If direct violence is the cause, the capsule and accessory band-like 
 ligaments are widely ruptured, and the head of the bone may pass 
 almost in any direction. In luxations caused by leverage (the usual 
 mechanism), the tear in the capsule always is sufficient to allow 
 passage of the head; but it is the capsule which ofFers the main obstacle 
 to reduction since by secondary displacement of the luxated bone, 
 and by its rotation on its long axis, the tear in the capsule becomes 
 converted into a slit with tense margins. But though this slit-like 
 opening in the capsule is the main obstacle to reduction further 
 
DismcArioNS 389 
 
 (.liffit'ulty is ailurcleci by muscular contraction and resiliency, wliicii 
 keep the hone in its ahnormal position. 
 
 Symptoms." Tlicrc are three cardinal syn)i)t()nis of dislocation. 
 (1 ) Ahcration in contour of the affected joint, the head of the hixated 
 bone l)ein<i absent from its socket and i)alpabK' elsewhere. (2) Change 
 in length of the affected extremity^either shortening or lengthening. 
 (8) Innnobility or loss of normal mobility. In many dislocations 
 there also is exident (4) Change in the axis of the dislocated bone. 
 The only pathognomonic sign, however, is the first, absence of the 
 head of the dislocated bone from its socket and its presence elsewhere; 
 and even here confusion may arise, if, as in cases of fracture of the 
 surgical neck of the scapula (p. 380), the socket as well as the head 
 of the l)one is displaced. In general, however, a dislocation may 
 be distinguished from a fracture near a joint, by the facts that in a 
 fracture there is abnormal mobility and bony crepitus; and that when 
 deformity is reduced it frequently recurs; whereas in dislocation the 
 normal mobility is decreased or entirely lost, there is no true crep- 
 itus, and deformity does not recur wdien the dislocation is reduced. 
 But in dislocation caused by direct violence the periarticular struc- 
 tures are so widely disrupted that abnormal mobility may exist, and 
 deformity may persistently recur; and in some cases there may be 
 an indistinct moist crepitus due to contrition of the luxated bone 
 with the side of the socket; moreover, dislocation and fracture may 
 be present in the same joint, symptoms of both conditions being 
 evident. The skiagraph offers a controlling test by which almost 
 always it is possible to ascertain the true lesion. 
 
 Damage to periarticular structures — nerves, bloodvessels, tendons — 
 may occur in dislocation, as in fracture, and always should be looked for 
 before attempts at reduction are made. Other evidences of local injury, 
 such as pain, swelling,ecchymosis, etc., do not require special description. 
 
 Changes in the Joint Surfaces occur within a comparatively short 
 time, if the dislocation is not reduced. There always is a certain 
 amount of blood extravasated, filling the capsule; and as this organizes 
 the socket becomes shallower, the capsular tear cicatrizes and con- 
 tracts, the surrounding ligaments, tendons, bloodvessels, and nerves 
 become adherent in the newdy formed scar-tissue; and the longer the 
 dislocation remains unreduced, the more difficult is it to secure 
 reposition. In the course of time the luxated bone forms for itself 
 a new socket, which will furnish a certain degree of solidity and 
 permits a moderate amount of motion. 
 
 Prognosis. — Prognosis is good in the majority of cases as to both 
 life and function. Dislocations very rarely are fatal injuries unless 
 compound or complicated. Beyond a weakness or stiffness lasting 
 some weeks or possibly months, most patients whose dislocations 
 have been promptly and skilfully reduced suffer no further incon- 
 venience; but where reduction is delayed, or where unusual force has 
 been employed in securing reduction, a certain amount of disability 
 may persist for years or throughout life. 
 
390 INJURIES OF JOINTS 
 
 Treatment. — In recent dislocations efforts at reduction should be 
 made at once, unless the patient is profoundly shocked. In many 
 cases general anesthesia is desirable to relieve the pain and abolish 
 muscular contraction, which is aroused anew at every attempt to 
 manipulate the limb. Dislocations are reduced by two methods, 
 which may be termed the direct and the indirect (G. G. Davis, 1910) : 
 in the former the limb is first placed in the attitude in which it was 
 when the dislocated bone burst through its capsule, and the head 
 of the bone is then pushed or pulled directly back tlirough the rent 
 in the capsule into its socket; in the indirect method the limb is 
 manipulated in such a way as to bring into use the capsule itself and 
 surrounding ligaments as a series of sliding fulcra, by means of which 
 the dislocated bone is levered into its socket. If an anesthetic is 
 administered, completely abolishing muscular contraction, no obstacle 
 to reduction remains except the joint capsule, and it depends on the 
 skill, patience, and dexterity of the surgeon to insinuate the head 
 of the dislocated bone tlirough the capsular opening into the socket; 
 for this to be accomplished, no force is required beyond what may be 
 exerted by the surgeon s hands. The capsule is an inelastic structure, 
 and the tear tlu-ough which the dislocated bone emerges always is 
 as large as and sometimes larger than the head of the bone itself. 
 If no anesthetic is given, it may be necessary to supplement the 
 surgeon's own power by weight-extension, gravity, etc., especially if 
 the patient has a highly developed muscular system; in other cases it 
 will be easy to reduce the luxation by taking the muscles by surprise, 
 as it were, and replacing the bone while the patient thinks a mere 
 preliminary examination is being conducted. 
 
 All efforts at reduction by conservative means having failed, the 
 surgeon may resort to artlirotomy, by which he will be enabled to 
 enlarge the rent in the capsule, and to displace tendons, ligaments, 
 etc., caught around the head of the bone, this latter condition being 
 almost the sole factor which renders a recent dislocation really irre- 
 ducible. Usually operation is not undertaken until several days 
 after the injury, various surgeons having meantime maltreated the 
 limb by applying excessive force in attempts at reduction; this renders 
 the operation more difficult and less likely to be successful than if 
 done before such unskilful attempts have been made. 
 
 Reduction having been secured, the joint should be kept at rest, 
 in such a position as to prevent re-dislocation, for a period of ten days 
 or two weeks; and for several weeks longer all violent motions, or 
 even gentle motions of wide range, should be prohibited. Massage 
 often is beneficial. 
 
 Compound Dislocations are to be treated according to the principles 
 inculcated when speaking of wounds of joints. Owing to the great 
 force necessary for their production, and the wide laceration of the 
 soft parts, reduction usually is easy. They are most frequent at the 
 elbow and ankle. 
 
SPECIAL DISLOCATIONS 301 
 
 Complicated Dislocations. Fniclurcs (•()iiii)li(:itiii^- dislocations are 
 discussed at \). '.W'l. Hiipliirf of Ihc iikiIii vessels at a dislocated joint 
 is to he treated as a wound of the \<'ssels under other circumstances. 
 Lesions of iwrirs acconii)anyint;- dislocation should he treated con- 
 servatively until no further improvement can be expected; unless, 
 of course, it is evident that complete rupture of a nerve trunk has 
 occurred, when primary suture should be done. 
 
 Old Dislocations. — Some dislocations become "old" much sooner 
 than others, and it is not always advisable to attempt reduction. 
 Sir Astley Cooper (1822) set three months as the limit for the shoulder, 
 and eight weeks for the hip, not because reduction could not sometimes 
 be obtained after the lapse of a longer time, l)ut because it was secured 
 at the ex})ense of such damage to the soft parts that the remedy was 
 worse than the disease. The first question, therefore, w-hich arises 
 in a ease of old dislocation, is whether or not reduction shall be at- 
 tempted. And it may be answered affirmatively in almost every 
 case, since even though the attempt prove a failure a skilful surgeon 
 by judicious and gentle manipulation of a dislocated joint almost 
 invariably wall be able to improve the function of the part. But 
 as to whether attempts at reduction will be successful, it is much 
 more difficult to formulate an answer, much depending on the duration 
 of the condition, the age of the patient, and the joint involved. At 
 the present day mere duration of the condition is very little con- 
 sidered, since should reduction fail by manipulation, it may succeed 
 by arthrotomy; and as a last resort the surgeon may have recourse 
 to excision of the joint or of the head of the dislocated bone, an 
 operation which generally will improve function, though not restoring 
 it to normal. But the age of the patient is an important consideration; 
 in the very old, wdiile manipulation might succeed in securing reduc- 
 tion more easily than in those of active middle life, yet the risk of 
 producing fracture w^ould be so great, and the advantages to be gained 
 so temporary, that as a rule it is better to leave the joint alone 
 unless the condition is very disabling. The hip-joint is that in wdiich 
 dislocation becomes irreducible most rapidly; the knee probably is 
 second, the elbow third, and the shoulder fourth. But in the hip 
 and the shoulder, especially the latter, if massage and passive motion 
 are persisted in long enough, a fair range of motion may be secured 
 wdthout reduction. In the elbow artlirotomy usually will be successful 
 in securing reduction and a useful limb; while in the knee excision 
 may be required. 
 
 Recurrent Dislocations are commonest at the shoulder, and may 
 require pleating of the capsule by suture as practised bv T. T. Thomas 
 (1909). 
 
 SPECIAL DISLOCATIONS. 
 
 Mandible. — Usually this is produced through muscular action in 
 yawning, though it may follow a downw^ard blow on the chin. The 
 luxation may be unilateral or bilateral, and the displacement nearly 
 
392 
 
 INJURIES OF JOINTS 
 
 invariably occurs forward: the condyle ruptures the weak anterior 
 portion of the capsular ligament, rides forward on the eminentia 
 articularis beyond its normal limit, and is held there by spasmodic 
 contraction of the external pterygoid muscle, assisted by the tem- 
 poral and masseter. The mouth remains open, and if only one side 
 of the jaw is dislocated, the chin is displaced to the other side. 
 
 Treatment. — Reduction is secured by forcibly opening the mouth 
 further, at the same time depressing the body of the bone by placing 
 the thumbs (carefully guarded by adhesive plaster, gauze, etc.) 
 over the back molar teeth, and finally raising the chin by the dis- 
 engaged fingers. Recurrence, not very rare, should be prevented by 
 application of a bandage, such as Barton's, for about ten days. 
 
 Subluxation of ilie jaw is a term employed by Sir Astley Cooper 
 (1S22) to describe a frequently repeated, usually self-reduced, uni- 
 lateral displacement of the mandibular condyle, due to looseness 
 of the intra-articular cartilage. In mild cases it constitutes the 
 condition known as "clacking jaw"; aside from the noise of the car- 
 tilage slipping around, which is audible to the patient and occasionally 
 to those close to him, little inconvenience is experienced. Treatment, 
 when any is required, consists in administration of tonics, use of 
 counter-irritants, injection of formalin or alcohol, and, as a last 
 resort, excision of the cartilage. 
 
 Central dislocation of the jaw is a very rare lesion, usually fatal, 
 in which the condyle is driven through the base of the skull. 
 
 Vertebrae. — See Chapter XVII. 
 
 Clavicle. — This bone may be dislocated at either end, dislocation 
 at the acromio-clavicular joint forming an exception to the rule for 
 nomenclature of luxations formulated at p. 388. 
 
 Fig. 393. — Mechanism of dislocation of 
 right sterno-elavicular joint. See text. 
 
 Fig. 394. — Mechanism of dislocation of 
 right acromio-cla\'icular joint. See text. 
 
 Dislocation of the Sterno-elavicular Joint. — The clavicle usually 
 is displaced upward and forward. The injury is produced by falls 
 or blows causing sudden depression of the shoulder, the clavicle 
 coming into contact with the first rib close to the sternum; as the 
 
DISLOCATION OF THE CLAVICLE 
 
 393 
 
 costo-c'lavit'ular lij^aiueiit prevents the ehiviele from ^nvinj^ at the 
 point of attaeliment, the inner extremity is pried out of its socket 
 over the first rih as a fuU-runi (Fi^. 
 ',\\y.\). The intra-articuhir cartihi^e 
 usually is disijlaeed with the clavi- 
 cle. Si/iiii)t(»)i.s are self-evident (Fi^- 
 39o), and reduction is easy to secure 
 by raisiuij; the outer end of the clavi- 
 cle and drawing the shoulder hack- 
 ward; but it is difficult to prevent 
 recurrence. The arm may be carried 
 in a sling, and a firm spica of the 
 shoulder a])plied (Fig. S()) with a 
 pad over the iinierend of the clavi- 
 cle. Some deformity almost always 
 persists, but function is good. In 
 some cases the joint may be opened 
 and the l)ones sutured in place. 
 Backward dislocation at the sternal 
 end is rare, and may be accompanied 
 l)y dyspnea, dysphagia, etc. In the 
 only patient I have .seen, under the 
 care of Dr. F. T. Stewart in the 
 
 Pennsylvania Hospital, the only pressure eflfects were due to com- 
 pression of the subclavian vein, and were promptly relieved by 
 drawing the shoulder backward. A posterior figure-of-eight bandage 
 
 Fi(i. 39."). — Kecunent dislocation of 
 sternal end of right clavicle. Ortho- 
 IJffidic Hospital. 
 
 Fig. 396. — Dislocated acromial end of right clavicle. Injury eighteen months ago. 
 
 Episcopal Hospital. 
 
 (Fig. 89) makes a good dressing. Downward dislocation at this joint 
 may occur when fracture of the first rib coexists; it is a serious 
 injury, the result of great direct violence. 
 
394 INJURIES OF JOINTS 
 
 Dislocation of the Acromio-clavicular Joint usually results from 
 depression and inward rotation of the scapula, from falls or blows 
 on the point of the shoulder. This carries the base of the coracoid 
 up against the clavicle, and as the clavicle is fastened to this by the 
 strong coraco-clavicular ligaments the only motion possible is an 
 upward displacement of the acromial end of the clavicle, the coracoid 
 acting as a fulcrum (Fig. 394). The deformity is self-evident (Fig. 396), 
 and like that at the inner end is easy to overcome but difficult to 
 keep reduced. However, by fixing the upper extremity in the Velpeau 
 position, with the dressing advised for fracture of the clavicle, the 
 turns of the bandage over the shoulder and under the flexed elbow 
 (Fig. 302) will keep the bones in place as long as the bandages remain 
 firm. This dressing should be continued two weeks or more. As in 
 luxation of the sternal end, suture may be adopted for persistent 
 deformity if it entails disability, which is rare. Doicmvard and back- 
 ivard dislocations occur, but are very unusual. 
 
 Scapula. — The only dislocation of this bone recognized by system- 
 atic writers consists in displacement of its lower vertebral border 
 from beneath the fibres of the latissimus dorsi, usually from indirect 
 violence or muscular strain. If firm bandaging is not sufficient, the 
 muscle may be re-attached by suture. The deformity seen in some 
 cases of phthisis (winged scapula), and after paralysis of the serratus 
 magnus muscle, closely simulates this "dislocation" of the scapula. 
 
 Shoulder. — Dislocations of the head of the humerus may occur 
 anterior or posterior to the glenoid cavity, the posterior variety being 
 exceedingly rare. There are many reasons for this: the shoulder 
 usually is dislocated by injuries which produce extreme abduction 
 of the arm, and as the force generally acts from the front, the arm 
 is carried backward as it is abducted. As the glenoid process looks 
 more forward than outward, such a motion tlirows most strain on 
 the anterior part of the capsule of the shoulder-joint; and if while 
 the arm is abducted slightly posteriori}^ an inward thrust or a pull 
 by the axillary muscles is added, this portion of the capsule will be 
 ruptured; or if abduction continues until the humerus strikes against 
 the acromion, after all possible leeway has been gained by rotation 
 of the scapula, then the head of the humerus will be pried out of 
 the capsule over the acromion as a fulcrum. The capsule is torn 
 loose from the glenoid, from the base of the coracoid above to the 
 attachment of the triceps below; and through this rent, which may 
 be increased by rotation of the humerus, the humeral head emerges 
 in the axilla, in front of the triceps. If the arm remains in the position 
 of extreme abduction, which is extremely rare, the condition is de- 
 scribed as luxatio erecta; usually, by the force of gravity or the assist- 
 ance of bystanders, the patient's arm is brought down to his side, 
 and the head of the bone passes beneath the coracoid (sub-coracoid 
 dislocation) where it usually remains, or may be displaced further 
 inward, into a subclavicular position. All these (axillary, subcoracoid, 
 subclavicular) are varieties of anterior dislocations. Posterior dis- 
 
DISLOCATION OF THE SHOULDER 
 
 395 
 
 locations, unless congenital, usuall\ result only from extreme direct 
 violence, tearin*,' loose li<,'aments and tendons on all sides; or some- 
 times by inward rotation and adduction, with a backward thrust, the 
 lesser tuberosity impinjiiuK on the coracoid pro(-ess. Sometimes 
 they are secondary disi)lacements, the primiti\e dislocation having 
 been anterior. The head of the bone may be displaced only slightly 
 backward {subacromial), or so far as to merit the term subspinous. 
 
 In anterior dislocations the subscapularis muscle, stretched over 
 the capsule at the point of rupture, may itself be perforated by the 
 head of the humerus, though usually this emerges below the sub- 
 scapularis. The circumflex or musculo-spiral nerve may be stretched 
 or lacerated, though recent observations seem to show that the 
 lesions if permanent more often are in the spinal roots forming the 
 outer cord of the brachial plexus (p. 28^). In most cases there is 
 tingling and numbness in the fingers, and some distention of the 
 veins, from pressure on the axillary vessels. 
 
 Fig. 397.— Recent subcoracoid luxation of left humerus, patient aged seventy years. 
 Reduced without anesthetic by Kocher's method. Episcopal Hospital. 
 
 Symptoms.— The appearance of patients with dislocation of the 
 shoulder is characteristic (Fig. 397) : the arm hangs a little away from 
 the side, there is a hollow under the acromion, and the head of the 
 bone may be seen beneath the coracoid. As the head of the humerus 
 has been displaced from its pedestal, and has been drawn against the 
 side of the thorax, and as the thoracic cage is convex, it is impossible 
 to bring the elbow against the side of the chest at the same time that 
 the hand is placed on the uninjured shoulder (Dugas's sign, 1856). 
 In recent cases, and in not very obese patients, the diagnosis is 
 easy; but when swelling has occurred, and after much manipulation 
 bv 'others, it mav be quite difficult; and it is in such circumstances 
 that Dugas's sign and the .r-ray (Fig. 398) become valuable aids. 
 
 In posterior dislocation the head of the bone is palpable beneath 
 
396 
 
 INJURIES OF JOINTS 
 
 the infraspinous muscles, the glenoid cavity is empty, the coracoid 
 process is unusually prominent, and the other usual symptoms of 
 dislocation are present. 
 
 Fig. 398. — Skiagrapli of suli-roracoid dislocation of humerus. (Coracoid and 
 glenoid processes emphasized.) Episcopal Hospital. 
 
 Treatment. — The indirect metJwd of reduction, or that by manipu- 
 lation, is preferable. This was proposed in 1858 by H, H. Smith, 
 Professor of Surgery in the University of Pennsylvania, and later 
 (1863) systematized by him; he thought muscular contraction, 
 especially that of the supraspinatus, as taught by Sir Astley Cooper, 
 was the main obstacle to reduction. Kocher, later Professor of 
 Surgery in Bern, in 1870 adopted a similar method, founded on that 
 of Schinzinger (1862) ; he recognized the capsule as the chief obstacle 
 to and best aid in securing reduction. 
 
 H. H. Smith's Method of Reduction. — The patient being on his 
 back, (1) elevate the arm in the sagittal plane until it is nearly vertical 
 (step two, of Kocher's method) ; this relaxes the supraspinatus muscle, 
 as well as the coraco-brachialis and short head of the biceps, per- 
 mitting step tw^o to be more efTectually executed. (2) Keeping the 
 arm vertical, and using the bent forearm as a lever, rotate the humerus 
 outward; by doing this the untorn posterior portion of the capsule 
 is wound around the head and upper part of the neck of the humerus 
 (Farabeuf, 1885), and acting as a sliding fulcrum draws the head 
 
DISLOCATION OF THE SHOULDER 
 
 397 
 
 of the bone Jiway from the chest, until the suhscapularis hcconies 
 tense and resists further rotation. (;3) Then slowly atiduct the arm 
 across the chest, still maintaining outward rotation of the humerus; 
 when the elhow touches the chest, th(> hand is brought down to the 
 opposite shoulder, and the hone usually will he rci)laced. 
 
 Fig. 399. 
 
 -Kocher's method of reducing dislocation of .shoulder, first step: outward 
 rotation. Episcopal Hospital. 
 
 T. Kuchcr's Method of Reduction. — (1) Bring the elbow against the 
 chest, and rotate the humerus outward as far as it will go, using the 
 bent forearm as a lever (Fig. 399) ; do not push this outward rotation 
 too far, and do it with a very gradual and gentle but persistent motion ; 
 force is very liable to fracture the humerus; Kocher himself broke 
 it three times in reducing twenty-eight luxations. During this out- 
 ward rotation of the humerus the same phenomena occur as during 
 
 Fig. 400. — Reduction of dislocation uf shoulder by Kocher's method; second step: 
 elevation of arm in sagittal plane. Episcopal Hospital. 
 
 step two of Smith's method, but the lesser tuberosity may catch under 
 the tense coraco-l)rachialis, and this is one cause of the frequency 
 of fracture of the humerus (G. G. Davis, 1910). (2) Raise the elbow 
 in the sagittal plane, or in slight adduction, until the arm is as nearly 
 vertical as possible (Fig. 400) ; this relaxes the anterior border of the 
 
398 
 
 INJURIES OF JOINTS 
 
 rent in the capsule (coraco-humeral ligament), and the coraco- 
 brachial is and short head of the biceps, which hinder the ascent of 
 the head on to the glenoid process. (3) Rotate the arm inward, 
 using the bent forearm as a lever, until the hand touches the sound 
 shoulder, then quickly bring the elbow to the side of the chest (Fig. 
 401). This last step slides the head of the bone back through the 
 rent in the capsule, whose posterior untorn part is now on the inner 
 instead of the outer side of the humerus, and again acts as a fulcrum 
 to lever the head upward; but reduction often is accomplished at the 
 conclusion of the second step. 
 
 Fig. 401. — Reduction of dislocation of shoulder by Kocher's method; third step: 
 hand brought to shoulder and elbow to chest. Episcopal Hospital. 
 
 Of these two methods, Smith's undoubtedly is the better, though 
 neither of them rests on the anatomo-pathological basis which was 
 erected for them by their authors; Smith thought the muscles the 
 all important factor, while Kocher thought success depended on the 
 gleno-humeral ligament, which was shown by Farabeuf to be of no 
 consequence. The great advantage of these methods of manipulation 
 is that an anesthetic usually is not required in recent cases, and that 
 they can be applied by the surgeon without other assistance than the 
 inertia of the patient's body. They depend for their efficiency, 
 however, on the untorn state of the posterior part of the capsule; if 
 this portion also is torn, the head of the humerus will not be pulled 
 away from the chest during outward rotation, but will rotate in situ. 
 Under such circumstances the rent in the capsule will be so large 
 that no difficulty should be experienced in replacing the head of the 
 bone by direct pressure, after it has been drawn away from the chest 
 by extension and counter-extension. 
 
 The methods of direct reposition are many; all of them depend 
 first on bringing the head of the bone opposite the tear in the capsule, 
 and consequently aivay from the chest umll and out to the neighborhood 
 of the glenoid process; and then on pushing or pulling it into its socket. 
 The head can be brought away from the side of the thorax only by 
 eliminating or overcoming the muscular contraction which holds 
 it there, either by continuous traction or a general anesthetic. 
 
DISLOCATION OF TlIM SIIOULDEIi :]{)9 
 
 1. Sir A.silcy Cooper's Method (1822): With tlic patient supine, 
 plaee the heel of the luihooted foot in the patient's axilla, against 
 the chest, and make traction downward and slightly outward on the 
 upper extreuiitx'; the traction ])ulls the head free from the eoraeoid, 
 and l)v slight Ie\erag{> o\(T the foot, the head is pushed directly 
 into its socket. A little rotation in and out may assist. This is a 
 very efficient method, really combining all others (extension and 
 counter-extension, leverage, and mauii)ulation), but it is very painful 
 and usually re(iuires anesthesia; and the inexpert or brutal may 
 cause serious injury to the axillary tissues. 
 
 2. Stimsons Method (1900: The patient is laid on a canvas sling, 
 with the dislocated extremity passed through a hole in the canvas 
 and hanging free of the floor; a weight of about ten pounds is attached 
 to the wrist or elbow. The liml) is kei)t thus in abduction, and in 
 a few minutes (never more than six, Stimson) reduction of the dis- 
 location takes place quietly and without pain. No anesthetic is 
 required, as the weight tires out the muscles which hold the head 
 of the humerus against the chest; and as soon as it is drawn out to 
 the region of the glenoid process, it slips into its socket spontaneously. 
 
 3. Malgaigne's Method (1855) is the reverse of Stimson's: The 
 patient lies on the sound side on the floor, and a robust assistant 
 pulls vertically upward on the dislocated extremity, till the shoulders 
 just clear the floor, and maintains this traction till the patient's 
 axillary muscles are exhausted; the surgeon then pushes the head 
 of the bone into place. 
 
 ]Many other modifications of this principle have been devised, and 
 constantly are being reinvented by ingenious surgeons. 
 
 In ijostcrior dislocations upon the cadaver I have succeeded in 
 securing reduction by reversing the manipulations of Kocher's and 
 Smith's methods; but usually in life the capsule is so widely torn 
 that the luxation is easily reduced by direct pressure forward or very 
 slight manipulation. 
 
 After reduction, the arm is dressed in the Velpeau position and 
 guarded use may be permitted after two weeks. It is possible that 
 if reduction were accomplished more often by manipulation and less 
 often by brute force less disability as the result of periarthritis would 
 follow this injury. Yvert (1911) has studied the statistics of various 
 surgeons and finds that 65 per cent, of the patients had persistent 
 disability, 22 per cent, had fairly satisfactory function, and only 
 13 per cent, had excellent results. 
 
 Elbow. — The typical dislocation at the elbow consists in backward 
 displacement of both bones of the forearm; anterior dislocation of both 
 bones is rare; and lateral dislocations usually are incomplete and often 
 accompanied by fracture of one or other of the humeral condyles. 
 
 Posterior Dislocation, — Posterior dislocation is most frequent from 
 fifteen to thirty years of age, and results almost invariably from a 
 fall on the out-stretched hand causing hyperextension of the elbow, 
 the olecranon acting as a fulcrum and prying the bones apart; the 
 
400 
 
 INJURIES OF JOINTS 
 
 anterior capsule is ruptured, and the internal lateral ligament more 
 or less lacerated, and detachment of the epitrochlea of the humerus 
 often occurs. Fracture of the olecranon by compression sometimes 
 is seen, and occasionally the coronoid process is broken off. 
 
 Fig. 402. — Old unreduced posterior dislocation of elbow, with evidences of hypertrophic 
 arthritis. Episcopal Hospital. 
 
 Symjjfoms. — The deformity usually is ciuite apparent. The fore- 
 arm, usually pronated, is carried at an obtuse angle with the arm, 
 and motion is painful and restricted. The radius and ulna may be 
 displaced directly backward, but often there is also slight lateral 
 displacement. The olecranon is found displaced posteriorly and 
 upward in relation to the condyles, and the greater sigmoid fossa 
 of the ulna often can be felt between the tense triceps and posterior 
 surface of the humerus (Fig. 402). The head of the radius is absent 
 from its normal place just in front of the external condyle and can 
 be felt posteriorly. Anteriorly the lower extremity of the humerus fills 
 the flexure of the elbow. The diagnosis from supracondylar fracture, 
 referred to at p. 341, should present no difficulties, and in case of 
 doubt, the lesion is much more likely to be a fracture than a dis- 
 location. If the lesion is recognized, and the luxation promptly 
 reduced, recovery is rapid, and in most cases nearly perfect function 
 is secured. 
 
 Treatment. — In recent cases, especially in children, reduction 
 without an anesthetic is easy, by reversing the steps by which the 
 lesion was produced: first hyperextend the elbow, until the tip of 
 
DISLOCATION OF THE ELBOW 
 
 401 
 
 the olocraiion strikes the humerus, and the coronoicl is freed from the 
 
 trochlea; tiien make extension and counter-extension in the axis 
 
 of the arm, pushing the lower end of the humerus backward; and 
 
 finally acutely flex the elbow, when the bones will be replaced with a 
 
 snap. Often the pressure of the 
 
 thumbs over the lower end of the 
 
 humerus, and that of tlie clasped 
 
 fingers over the posterior surface 
 
 of the olecranon, is sufficient to 
 
 secure reduction (direct method); 
 
 or the knee may be placed in the 
 
 bend of the elbow and used as a 
 
 fulcrum to lever the bones of the 
 
 forearm away from the humerus 
 
 by traction on the wrist with one 
 
 hand, while the humerus is pushed 
 
 backward with the other hand 
 
 (Fig. 403). The elbow is dressed 
 
 in hyperflexion (p. 347), for a 
 
 week, and then carried in a sling for another, and after two weeks 
 
 guarded active use is encouraged. 
 
 Lateral Dislocation. — External dislocation often is due to direct 
 violence, usually is incomplete and complicated by fracture of the 
 external condyle, and extensive rupture of the internal lateral ligament 
 
 Fig. 403. — Mechanism 
 po.sterior di.slocatioii of i 
 the knee. 
 
 of reduction of 
 ;lljow by aid of 
 
 Fig. 404. — External lateral disloca- 
 tion of elbow, with fracture of external 
 condyle, and rupture of internal lateral 
 ligament and fracture of epitrochlea. 
 Dr. W. Walker's case. Episcopal 
 Hospital. 
 
 Fig. 40.5. — Inward dislocation of ulna and 
 radius. Dr. De Tar's case. Patient fell and 
 while lying on left elbow train struck him 
 upon buttocks. Reduction easy under anes- 
 thetic. 
 
 (Fig. 404). Internal dislocation is rarer than external, and fracture is a 
 less usual complication (Fig. 405). In both forms the deformity is 
 so extreme and the bony processes so easily palpable that, if careful 
 examination is made before swelling obscures the landmarks, the 
 26 
 
402 
 
 IXJCRIES OF JOINTS 
 
 diagnosis should not be difficult. Reduction is easier to secure than 
 to maintain, especially if fracture exists. The elbow should be dressed 
 in hyperflexion and treated as a fracture. 
 
 Forward Dislocation. — Forward dislocation of both bones at the 
 elbow is very rare; even including seven cases in which the olecranon 
 was broken off and remained in place, the total number on record, 
 according to Stimson, is less than twenty-five. Fracture of the epi- 
 trochlea is a frequent accompaniment. Reduction is not difficult, as 
 both lateral ligaments are lacerated. 
 
 Dislocation of the Ulna Alone from the humerus is most often pos- 
 terior; the symptoms and treatment are much the same as when both 
 bones are so displaced. 
 
 Fig. 406. — Anterior and outward dislocation of head of radius, with fracture of 
 shaft of ulna. Four months after injury. Episcopal Hospital. 
 
 Dislocation of the Head of the Radius usually occurs in an anterior 
 direction. The orbicular ligament may remain intact, the radius 
 slipping out of its grasp, and subsequently being displaced forward 
 by the pull of the biceps; often it is the result of a fracture of the 
 upper part of the shaft of the ulna, from direct violence, the con- 
 tinuance of the fracturing force driving the head of the radius forward 
 (Figs. 40(3 and 407). This combined lesion is so freciuent that the 
 recognition of either a dislocation of the radial head or a fracture of the 
 upper end of the ulna should make the surgeon suspect the existence 
 of the complicating lesion. Examination may detect a hollow in front 
 of the external condyle, and the head of the radius a little forward 
 from its normal position; flexion of the elbow beyond a right angle may 
 be prevented by contact of the radius with the humerus. Reduction 
 sometimes may be secured by full supination and direct pressure 
 upon the displaced bone; and flexion will then become possible. 
 
DISLOCATION OF THE WRIST 
 
 403 
 
 Reduction sliould he obtained at all hazards, l)y arthrotomy it' neces- 
 sary. Only after reduction of the radial flislocation has heen secured 
 can the fracture of the ulna he reduced. If re-dislocation of the radial 
 head occurs after keepin<; the elbow hyperflexed (p. ?A1) for several 
 weeks, it may be assumed that the radial head had not been replaced 
 within the orbicular lijjament; and an operation may be necessary 
 to hold it in i>lace. In cases of complete dislocation it is very unlikely 
 that reduction can be secured without operation. In old unreduced 
 luxation, excision of the radial head may be done to permit flexion 
 of the elbow, but in children this should be avoided if possible, since 
 removal of the ei)ii)hysis will interfere with development. 
 
 Fig. 407. — Anterior and outward dislocation of head of radius, three months after 
 reduction by arthrotomy and capsulorrhaphy. Episcopal Hospital. 
 
 In young children a subluxation known as "pulled elbow" occurs: 
 this is due to vertical traction on the forearm, often produced as the 
 caretaker helps or lifts the child across an obstruction in the street. If 
 the forearm is supinated the vertical traction tends to bring the fore- 
 arm and arm into a straight line, causing momentary loss of the carry- 
 ing angle; or forced pronation may pry the radius forward over the 
 ulna as a fulcrum. Symptoms of pulled elbow are rather indefinite, 
 and in many cases no definite history of trauma can be obtained; it 
 is merely noticed that the arm is not used properly, and that there is 
 tenderness around the elbow. Treatment of "pulled elbow" consists 
 in securing reduction of the subluxated bone by the same methods 
 employed in cases of complete dislocation, and in preventing recurrence 
 (which is not very rare) by keeping the elbow at rest for a week. 
 
 Wrist. — Dislocation of the radio-carpal joint, usually consisting 
 in dorsal displacement of the carpus, is very rare; Stimson classes 
 Barton's fracture (p. 355) more as a complication of this dislocation 
 than as an independent lesion. It is produced usually by the 
 same injuries as Colles's fracture, and the differential diagnosis is 
 
404 
 
 INJURIES OF JOINTS 
 
 not always easy; but if it is possible to feel the styloid processes of 
 the radius and ulna still attached to their respective bones, and to 
 ascertain that the length of the bones of the forearm remains the same 
 on both sides of the body and to feel the very abrupt eminence on 
 the dorsum caused by the displaced carpal bones, confusion between 
 fracture and dislocation is not apt to occur. Besides, the luxation 
 is reduced by an elastic snap, without crepitus, and without tendency 
 to recurrence. I have seen one case myself, easily diagnosed clinically 
 by attention to these details. The diagnosis may be confirmed by 
 a skiagraph. 
 
 Spontaneous Siihhi.ratiun of the Wrist {Madelumfs Disease). — See 
 p. 542. 
 
 Dislocations of the carpal hones are not very uncommon, particularly 
 forward dislocation of the semilunar, associated or not with fracture 
 of the scaphoid. The bone is palpable under the flexor tendons, 
 and there is a gap on the extensor surface between the os magnum 
 and radius. The other carpal bones, most often scaphoid or os mag- 
 num, usually are dislocated backward. If reduction is not easily 
 secured, the displaced bone should be excised. 
 
 Metacarpus. — The metacarpal bones rarely are luxated, the dis- 
 placement usually being posterior. 
 
 Phalanges.— The proximal phalanx of the thumb not infreciuently is 
 dislocated posteriorly on the head of its metacarpal bone by hyper- 
 extension, sometimes in a fight, 
 a fall, or in the effort to push 
 a tight stocking off the heel of 
 the foot. The deformity is 
 quite characteristic (Fig. 408), 
 the phalanx in well-marked 
 cases making a distinct angle 
 with the metacarpal bone, the 
 head of which is easily palpable 
 in front; the distal phalanx 
 remains flexed, owing to ten- 
 sion on the flexor longus pol- 
 licis, which is displaced to 
 one side or other, usually 
 the ulnar side of the metacarpal. The head of the metacarpal is 
 "button-holed" through the anterior ligament; the tendons of the 
 flexor brevis blend with the lateral ligaments, and it is the tension of 
 these lateral ligaments, which fit like a collar around the neck of the 
 metacarpal, that may render reduction impossible. In some cases 
 reduction can be effected without anesthesia, (1) by pressing the 
 metacarpal bone toward the palm, so as to relax the short thumb 
 muscles; (2) by sliding the base of the phalanx over the head of the 
 metacarpal, keeping the phalanx in hyperextension until the head of 
 the metacarpal has been cleared. If reduction is impossible, an 
 incision is made along the radial border of the flexor surface of the 
 
 Fig. 408. — Dislocation of metacarpo-phalan- 
 geal joint of thumb. Reduced by arthrotomy. 
 Episcopal Hospital. 
 
DISLOCAriON OF THE HIP 
 
 40.") 
 
 j)r()iniii(Mit liciid of the tliuml) iiictacarpiil, :iih1 tlic cxtcriKil liitcnil 
 li<,Miiu'nt is (li\i(lc(l close to the pluihiiix. 
 
 J)i,s'locaii(m.s of tlir inlrriihdhiiKjnd johils of the lingers almost 
 always takes place posteriorlx , from li\ iMTextensioii, in falls or l)lo\vs 
 on tiie fin<,'er tips (V\^. 4()i»). Hediiction usually is easy, but a joint 
 fracturi' of the i)roxinial hone may exist, and some deformity may 
 result. Treatment is the same as for fracture of a i)halanx. Jjitrntl 
 dislocation usually is ineom])lete (Fig. 410). 
 
 Fig. 409. — Posterior dislocation of 
 niitldle phalanx on iiroximal of fifth 
 finger. Episcopal Hosijital. 
 
 Fig. 410. — Lateral dislocation of mid- 
 dle on proximal phalanx. Episcopal 
 Hospital. 
 
 Sacro-iliac Joints. — ('omplete luxation is rare, hut subluxation, 
 from sprain or long-continued strain is not unusual. ^Motion occurs 
 antero-posteriorly around a transverse axis, and the usual displace- 
 ment is of the upper end of the sacrum backward. Cricks and stitches 
 in the small of the back, or severe backache may follow strain on 
 these joint ligaments from stooping, from malposition in sitting or 
 standing, or simply from lying long flat on the back, when the mus- 
 cular support is weakened by anesthesia or constitutional disease. 
 Relaxation of these joints sometimes is seen, and is best treated by 
 orthopedic apparatus, gymnastics, etc. (p. 535). 
 
 Hip. — Dislocation of the hip is a rare and rather a serious injury. 
 The head of the femur is held in the acetabulum by a capsular ligament 
 which is reinforced above and below by l)and-like ligaments, leaving 
 the capsule weak anteriorly and posteriorly. The upper band-like 
 ligament (ilio-femoral ligament of Bertin, 1754) is especially strong, 
 and is known as the Y-ligament of Bigelow^ (1869); it is scarcely 
 ever ruptured, no matter what the force that produces the luxation. 
 Indirect violence is the usual cause, the femur being forced beyond 
 its normal range either in flexion and adduction, or in extension and 
 abduction, and the head of the bone being pried out of the acetabulum 
 by leverage. In the cadaver luxations are most easily produced by 
 hyperabduction, forcing the great trochanter against the posterior 
 lip of the acetabulum, and using it as a fulcrum by which the head is 
 lifted out of its socket; the capsule is then ruptured anteriorly below 
 the ilio-femoral ligament, and the head of the bone passes on to the 
 anterior plaiie^ of the innominate bone (Fig. 411). In patients, how- 
 
 1 Nekton's line divides the innominate bone into two planes (Alli.s, 1S96). 
 
406 
 
 INJURIES OF JOINTS 
 
 Fk;. 411. — Innominate bone showing the 
 anterior and posterior planes. University of 
 Pennsylvania. 
 
 ever, the history of the injury generally indicates another mechanism, 
 the femur having been in flexon and adduction, and the force having 
 been received through an upward thrust in the long axis of the femur, 
 or by a heavy weight falling on the pehis from behind. In such 
 cases it is probable that the strong ilio-femoral ligament has been 
 wound around the neck of the femur (inwardly rotated), acting as a 
 
 sliding fulcrum; or possibly 
 that the neck of the femur 
 has been forced against the 
 horizontal ramus of the pubis, 
 and that the head has been 
 pried out of the acetabulum 
 over thi^ as a fulcrum. The 
 capsule here is ruptured pos- 
 teriorly, and the femoral head 
 passes on to the posterior 
 yJane of the innominate bone. 
 Owing to the immense length 
 of the distal arm of the lever 
 (the whole lower extremity), it 
 is not at all unusual for a dis- 
 location primitively anterior to be converted into one of the posterior 
 variety secondarily; in such cases the capsule may be widely lacerated, 
 but in almost every case the ilio-femoral ligament remains intact, and 
 the lower extremity is circumducted and rotated on it as a pivot. 
 
 In general, then, two main types of dislocation at the hip may be 
 recognized, anterior and posterior; and of each type there are several 
 varieties, according as 
 the head of the femur J 
 
 rests high or low on the 
 anterior or posterior 
 plane of the pelvis (Fig. 
 412). 
 
 Posterior Dislocations of 
 the Hip, more frequent 
 than anterior, are classed 
 as high ("dislocation on 
 the dorsum ilii," or 
 "above the tendon" of 
 the obturator internus), 
 and low ("dislocation into 
 the sciatic notch" of Sir 
 Astley Cooper, 1822; or "below the tendon" of Bigelow 1869); and 
 of these two the high luxation is much more frequent, though this 
 may be only a secondary displacement, the head of the femur 
 having emerged from the capsule lower than the sciatic notch, and 
 having been displaced upward when the limb was extended. 
 
 Fig. 412. — Usual sites of dislocation at the hip. 
 A to B, Nelation's line. Posterior dislocations are 
 (1) low; (2) high. Anterior dislocations are: (8) low; 
 (4) high. See text. 
 
DISLOCATION OF THE II W 
 
 407 
 
 ^ynii>Uwts.-'T\\vve is loss of normal mohility; there is shortening, 
 with flexion, addnetion and internal rotation at the hip; and in stand- 
 ing the toes of the injured side rest on the dorsum of the other foot 
 (^\^ 4i:i). The lower the position of the femoral head on the posterior 
 
 Fig. 413. — Posterior (dorsal) dislocation of the hip. (Stinison.) 
 
 plane, the more marked will be the shortening, flexion, adduction, 
 and inward rotation. The head of the femur^ can no longer be felt 
 below Poupart's ligament, beneath the femoral artery, but sometmies 
 
 1 A good working rule to remember is that the position of the internal condyle 
 corresponds 1o that of the head of the femur, while that of the external condyle 
 corresponds to that of the great trochanter (G. G. Davis, 1910). 
 
408 
 
 INJURIES OF JOINTS 
 
 can be detected posteriorly under the gluteal muscles; the trochanter 
 is unduly prominent, is rotated forward, and is above Nekton's line. 
 Anterior Dislocations of the Hip are classed as high ("pubic"), or 
 low ("thyroid"), the latter, in which the head rests in the obturator 
 foramen, probably being the primitive form in most cases; in the 
 pubic form, the head rests against the horizontal ramus of the pubis; 
 an exaggerated form of the high dislocation is the "suprapubic," and 
 an exaggerated form of^the low dislocation is the "perineal," the 
 
 head of the bone passing inward be- 
 yond the thyroid foramen and across 
 the ischium into the perineum. 
 
 Symptoms. — ^AU these anterior dis- 
 locations are characterized by im- 
 mobility, flexion, abduction, and 
 eversion of the limb (Fig. 414); in 
 the low forms there may be apparent 
 lengthening, but in the high cases 
 there usually is actual shortening. 
 The head of the femur generally can 
 be felt beneath the pectineus or ad- 
 ductor muscles, and often forms a 
 visible prominence; the trochanter is 
 rotated backward, and is less promi- 
 nent than normally. 
 
 Other Atypical or "Irregular" Dis- 
 locations of the Hip occur, but are 
 extremely rare, and are either sec- 
 ondary modifications of those de- 
 scribed above, or are caused by such 
 \iolent trauma as frequently to cost 
 the patient his life. The so-called 
 "central dislocation of the hip" is 
 discussed at p. 325. 
 
 Prognosis. — If reduction is effected 
 promptly, and without additional 
 trauma, restoration of function is 
 rapid, and generally complete; but 
 Pennsylvania Hos- the longer rcductiou is delayed, and 
 the greater the force required in ac- 
 complishing it, the more unfavorable 
 the outlook. But even in some cases of irreducible luxation, especially 
 of the thyroid type, very fair use of the limb may be secured. 
 
 Treatment. — Reduction of dislocation of the hip is accomplished 
 either by the direct or indirect method. 
 
 Direct Method. — In this, systematized by Allis (189G), the head of 
 the femur is first brought into the position in which it burst tlirough 
 the capsule, and is then pushed or pulled into the acetabulum. 
 As in both anterior and posterior dislocations the head leaves the 
 
 Fig. 414, 
 location of hip 
 pital. 
 
 Anterior (thyroid) 
 
DISLOCATION OF THE HIP 
 
 409 
 
 acrtabiiliim in its lowor i)art, and as the capsnlc i)r(>l)al)Iy is widely 
 torn below, the method ot" direct reposition is nearly the same for both 
 varieties. The patient should be anesthetized anil laid on his back 
 on a mattress on the floor, with the pelvis firmly fixed: flex the t\\\^\\ 
 on the pelvis to a riu;ht an<(le, thus brin<;inff the head of the fenuir 
 toward the lower part of the acetabulum; flex the knee to a ri<i;ht anj,de, 
 to relax the hamstring muscles and sciatic nerve, and to aid in rotating 
 the thigh. Hold the ankle with one hand, and pass the other hand 
 beneath the flexed knee or sling a towel under the knee and over your 
 own shoulders, to aid in the upward traction required. In hackifard 
 dislocation have the thigh slightly adduried, to free the head from 
 the rim of the aceta])ulum and to relax the anterior branch of the 
 
 Fig. 415. — Position of bones in reduction of posterior dislocation of hip by direct 
 method. University of Pennsylvania. 
 
 Y-ligament; then make vertical traction on the thigh upward and 
 a little imcard, and the head may jump into the acetabulum (Fig. 
 415). If it does not, rotate the thigh gently in and out (do not 
 circumduct it), to make the capsule gape widest, and try to pull 
 the head over the rim of the acetabulum in the various positions 
 of rotation. An assistant may help by direct pressure upward 
 and inward on the great trochanter. The head usually will jump 
 into the acetabulum with an audible snap. In forward dislocation, 
 have the thigh slightly abducted, to free the head from the antero- 
 inferior margin of the acetabulum, and to relax the posterior branch 
 of the Y-ligament; then make vertical traction upward and slightly 
 outward, and the head often will jump into the acetabulum (Fig. 41()). 
 If not, gentle rotation may be tried, until the capsule gapes its widest; 
 
410 
 
 INJURIES OF JOINTS 
 
 and an assistant may aid by pushing the trochanter upward and 
 slightly outward. 
 
 In Stimson's application of the direct method (1889) for posterior 
 dislocation, the patient lies prone, with the affected thigh hanging 
 vertically downward: the knee of the dislocated side is flexed, and 
 the ankle held by the surgeon; in most cases the weight of the limb 
 is sufficient to reduce the dislocation within a few minutes without 
 pain and almost imperceptibly; if necessary, weight may be added t<j 
 the knee, and gentle rotation practiced, as when the patient lies on 
 his back. 
 
 Fig. 416. — Position of bones in reduction of anterior dislocation of hip by direct 
 method. University of Pennsylvania. 
 
 Indirect Method. — Reduction by manipulation alone was taught 
 and practised by Hippocrates, N. R. Smith (1831), and Despres 
 (1835), and was systematized by ^Y. W. Reid (1851); they regarded 
 the muscles as the chief ob.stacles to reduction; but it remained for 
 Moses Gunn (1853) and especially for Bigelow (1869) to demonstrate 
 that even wdth muscular contraction abolished by anesthesia, the 
 capsule still remained the supreme obstacle, and that manipulation 
 was successful only when the action of the Y-ligament was appreciated 
 and employed as an aid. It is used as a sliding fulcrum over which 
 the head of the femur rides into the acetabulum. The patient is 
 anesthetized, and laid on his back on a mattress on the floor; with 
 the pelvis firmly fixed, the thigh is flexed on the pelvis to relax the 
 Y-ligament and to bring the head of the bone down to the lower 
 part of the acetabulum near the rent in the capsule; and the leg is 
 
DISLOCATION OF THE 11 W 
 
 411 
 
 flexed on the X\\'v^\\ to aid in the nianipnhition, and to rehix the ham- 
 strings and seiatie ner\e. In po.strrior diskx-ations tlie linih is l)rouglit 
 up in the position in which it is found (adduction), and is gently circum- 
 ducted and rotated outward after the thigh lias been flexcfl to more 
 than a right angle with the pelvis; as outward circumduction is con- 
 tiiuied (Fig. 417), the head of the hone is swung downward and inward 
 by tension on the posterior branch of the Y-ligament, and linally 
 as the limb is brought down to the position of full extension and 
 very slight abduction, the head rides over the rim of the acetabulum 
 ami sinks into its socket. If the abduction is too great as the thigh is 
 brought down to extension, the head will slide across to the anterior 
 plane of the pelvis, and a secondary thyroid luxation will be produced. 
 Rarely in this excursion the sciatic nerve may be caught up over the 
 neck of the femur. If abduction is not great enough, the head will 
 slide up again on the outer side of the acetabulum, and the high 
 posterior luxation will be reproduced. Rarely as it slides up it may 
 
 Fig. 417. — Reduction of backward dis- 
 location of femur. (Bigelow.) 
 
 Fig. 418. — Reduction of downward and 
 forward dislocation of femur. (Bigelow.) 
 
 catch under the tendon of the obturator internus. In anterior dis- 
 locations the limb is brought up in the position in which it is found 
 (abduction), and is gently circumducted and rotated inw^ard after 
 the thigh has been flexed to more than a right angle with the pelvis; 
 as inward circumduction is continued (Fig. 41 S), the head of the bone 
 is swung downward and outward by tension on the anterior l)ranch 
 of the Y-ligament; and finally as the limb is brought down to the 
 position of full extension and very slight adduction, the head rides 
 over the rim of the acetabulum into its socket. If the addvction is 
 too great, a secondary posterior dislocation may be produced; and 
 if it i^ 7iot great enough, the head will slide up the inner side of the 
 acetabulum to a pubic position. 
 
 Reduction is known to have been accomplished when the head 
 of the bone is felt to snap into place, and it can be felt rotating in 
 its socket by the fingers below Poupart's ligament; when normal 
 extension of the hip is possible, and when a skiagraph shows the 
 bones in place. 
 
412 
 
 rXJURIES OF JOINTS 
 
 Ajter-ireaiment. — The patient should be kept in bed with moderate 
 weight-extension for a couple of weeks, and should resume use of 
 the limb with caution. 
 Patella. — See page 279. 
 
 Knee. — Traumatic luxations of the knee are extremely rare, and 
 usually caused by very severe injuries. The displacement of the 
 head of the tibia may be backward, forward, lateral, or rotatory. 
 Wise (1909j refers to 270 cases of dislocation of the knee, 114 of which 
 were anterior. Most of the displacements are incomplete, the lateral 
 almost invariably. Forward dislocation is caused by sudden violent 
 hj-perextension, by indirect or direct violence; the tibia slides up 
 on the front of the condyles, but usually maintains the same axis 
 as the femur, not being flexed or hyperextended. Backward dis- 
 location usually follows direct force applied to the front of the tibia, 
 and the leg becomes hyperextended on the tliigh. In many of these 
 luxations injuries to the popliteal vessels or nerves are present, and 
 the intra-articular cartilages and ligaments may be ruptured. Usually 
 reduction is not very difficult, owing to stretching or laceration of 
 the lateral ligaments. Prognosis as to function is not very good 
 even in uncomplicated cases, some deformity fflexion, valgus, etc.), 
 generally persisting through life; and for complications, amputation 
 may be required. 
 
 Fracture or Subluxation of the Semilunar Cartilages Internal De- 
 rangement oj the Knee-joint, Hey, 1S03). In these cases there may 
 
 be a sprain, or slight twist of the knee, 
 which, while the patient is walking, sud- 
 denly becomes locked in a flexed position; 
 at the same time excruciating pain may 
 be felt, and sometimes a palpable lump 
 appears below the internal condyle. The 
 lesion usually consists in detachment of 
 the internal semilunar cartilage from the 
 head of the tibia; sometimes a piece of it 
 is broken off, and slipping outward, locks 
 the knee-joint. As a rule gentle mani- 
 pulation and gradual passive extension 
 -o far as possible, followed by sudden 
 acute flexion of the knee will reduce the 
 deformity, and restore the movements of 
 the joint. The same train of symptoms, 
 however, frequently recurs, and may be 
 due not to detachment or fracture of a 
 cartilage, but to the presence of "joint 
 mice" (p. 461), the result of chronic 
 articular disease. 
 Treatment. — After reduction of the deformity some appliance must 
 be worn to limit motion in the knee, and to prevent rotation. If 
 the patient is anxious for a radical cure, arthrotomy may be done 
 
 Fig. 419. — External semilunar 
 cartilage removed from knee, for 
 dislocation. Episcopal Hospital. 
 
DISLOCATION OF THE ANKLE 
 
 413 
 
 preferably tlir()iijj;h a transverse incision directly over the luxated 
 cartilaj^e, which is caught in a shar{) hook or volsellum forceps and 
 renio\e(l (i'^ii;:. 415)). Attempts to suture it in i)lace are not advisable. 
 Function nearly always is completely restored. Arthrotomy for the 
 removal of "joint mice" is best done by a longitudinal incision along 
 the inner border of the patella, whicli may then be displaced outward, 
 as the knee is Hexed, widely exposing the joint. 
 
 Fig. 420T — Skiacraph of fracture-dislocation of astragalus. Age forty-five years. 
 From fall of eight feet, landing on feet. Irreducible. Both fragments excised. Excel- 
 lent result. Episcopal Hospital. 
 
 Ankle. (Tibiu-tarsal Joint). — Except in connection with fracture 
 of the leg bones, dislocations at the ankle-joint are exceedingly rare. 
 Wendel (1898) collected 108 cases without fracture. Posterior luxa- 
 tion usually follows forced plantar flexion of the foot, with rupture 
 of the lateral ligaments of the ankle, the astragalus sliding backward 
 oflf the tibio-fibular mortise as dorsal flexion is regained. Anterior 
 luxation, much rarer, usually occurs when the foot is in extreme 
 dorsal flexion, the leg bones being forced backward against the tense 
 tendo Achillis either by a blow from above or by a fall on the heel. 
 Lateral dislocation is that in which the astragalus and with it the 
 foot, leaves the tibio-fibular mortise, and is displaced externally or 
 internally, there being little or no rotation of the foot. A less unusual 
 displacement is that in which the astragalus rotates around an antero- 
 posterior axis, so that the sole of the foot looks either inward (supina- 
 tion dislocation) or outward {pronation dislocation). If, on the other 
 hand, the astragalus rotates around a vertical axis, it may remain 
 
414 
 
 INJURIES OF JOINTS 
 
 in the tibio-fibiilar mortise, but the entire foot may rotate with it 
 the toes looking inward and the heel outward in (Ushcation hy inver- 
 sion, and the opposite being the case in dislocation by cversion. Dis- 
 location iqncard (the astragalus separating the tibia and fibula) is 
 known by Nelaton's name, though his case was complicated by 
 fracture. Unless swelHng obscures bony landmarks, these various 
 forms can be distinguished clinically; but in all cases it is desirable 
 to have skiagraphs made in at least two planes. These dislocations 
 about the ankle-joint frequently are compound, and as already 
 remarked, fracture of some of the bones involved very rarely is 
 absent (Fig. 384). Reduction is not always possible without incision, 
 and should be accomplished on the day of injury if possible. The 
 longer the bones remain out of place, the less favorable will be the 
 prognosis for function. 
 
 Fig. 421. — Skiagraph of upward dislocation of tarsal scaphoid. Age fifty-four years. 
 
 Episcopal Hospital. 
 
 Tarsus. — The astragalus may be the subject of an isolated dis- 
 location forward or backward, the latter being much rarer, and the 
 forward displacement usually being somewhat inward or outward 
 as well; or the astragalus may be rotated in any axis, remaining in 
 situ. If reduction is not possible by manipulation, aided perhaps 
 by tenotomy of the tendo Achillis, arthrotomy should be done, and 
 the astragalus removed unless reduction is easy. Good function 
 followed astragalectomy for fracture-dislocation in the case repre- 
 sented in Fig. 420. Isolated dislocation of the other tarsal bones 
 
DISLOCATION OF THE FOOT 
 
 415 
 
 may occur (Fig. 421); unless reduction is easy, the displaced bone 
 should 1)C excised. Siiha.s-lraguldr (Usioration of the foot, of which 
 Wise (1909) has collected S7 examples (oO inward, 21 outward, 
 S anterior, and <S posterior), consists of displacement of the entire 
 foot from the astrajjjalus, which remains in the tibio-fibuiar mortise. 
 Reduction usually is possible by manipulation, and may be aided 
 by tenotomy of the tibialis anticus, or by incision, if necessary. For 
 compound dislocations amputation may be required. 
 
 Dislocation at the mcdio-tarsal joint is rare. Skillern (191.'i) reports 
 what he considers the thirteenth authentic case on record. The 
 anterior tarsus may be displaced toward 
 the flexor or extensor surface. Reduction 
 usually is possible by manipulation under 
 an anesthetic. 
 
 Metatarsus. — Dislocations of the meta- 
 tarsals have been studied at length by 
 Quenu and Kiiss (1909); they collected 
 35 cases, and believe that systematic 
 radiographic study will show it to be 
 rather a freciuent lesion of the foot. It 
 frequently is complicated by fracture, and 
 usually is due to direct violence or to 
 falls on the toes. They show that the 
 foot may be divided into two structural 
 parts, as in Fig. 422, of which the main 
 weight-bearing part is composed of the 
 tarsus and the first metatarsal with its 
 phalanges, while the four outer meta- 
 tarsals serve as a balance. The most 
 frequent luxations are (1) one in which 
 the balancing portion is displaced exter- 
 nally and toward the dorsum of the foot 
 
 (external dorso-lateral dislocation) , and (2) one in which there is a dis- 
 placement of the balancing portion outward and of the first meta- 
 tarsal inward (divergent dislocation). Diagnosis depends largely on 
 radiography. If reduction is impossible by manipulation, operation 
 may be done; this cannot be made to conform to any type, but may 
 involve tenotomy, arthrodesis, removal of fragments, etc. But even 
 in cases not reduced, fair use of the foot may be regained after 
 scA'eral months or a year. 
 
 Phalanges. — Dislocation of the phalanges of the toes are rare, 
 usually due to direct violence, and hence often compound. Reduction 
 and treatment are the same as in the fingers. 
 
 Fig. 422. — The structural por- 
 tions of the foot concerned in 
 metatarsal dislocations. (Quenu 
 and Kiiss.) 
 
CHAPTER XIV. 
 DISEASES OF BONE. 
 
 DYSTROPHIES OF BONE. 
 
 There are numerous affections of bone of whose nature patholo- 
 gists are still in ignorance. Some of them are known to be associated 
 with changes in the organs of internal secretion; some of them may 
 be due to remote infections, to chronic toxemias or intoxications; 
 but all that is certain is that they depend on disturbances of nutri- 
 tion, and for that reason it is convenient to group them together as 
 dystrophies. In most cases the osseous system alone is not affected, 
 but is more conspicuously diseased than the soft tissues. The diseases 
 in question range from atrophic to hypertrophic forms, but in many 
 both atrophy (softening) and hypertrophy (hardening) are present 
 coincidently, or at different stages of the same disease. Congenital 
 malformations are mentioned in the chapter on Orthopedic Surgery 
 (Chapter XVI). 
 
 Atrophy of Bone. — This may be concentric or eccentric (Fig. 423). In 
 the former variety, which begins at the periosteal surface, the size of 
 the bone decreases, but its length (due to cartilaginous growth) is 
 little affected, and what once was a strong shaft becomes a mere 
 spindle. In eccentric atrophy the changes begin in the marrow, 
 and, though the bone may not change in size, it becomes weaker 
 and more porous. In both forms the pathological changes consist 
 in absorption of the bony trabecule by giant cells (osteoclasts), 
 with the deposit of fat in the lacunae {lacunar resorption). If the 
 bone becomes fragile and brittle, there is said to be osteopsathyrosis, 
 or fragilitas ossium; if it merely becomes light and porous, without 
 tendency to fracture, the condition is known as osteoporosis. 
 
 Causes. — Causes of bone atrophy are disuse (as in amputation 
 stumps, paralyzed limbs, etc.); chronic disease, especially of the 
 nervous system; and old age. In most cases disuse is the paramount 
 cause. Atrophy from pressure is also seen, as in tumors, aneurysms, 
 etc. 
 
 Osteogenesis Imperfecta. — Osteogenesis imperfecta, the so-called 
 "idiopathic fragilitas ossium," is considered a definite disease; it 
 is congenital, may be hereditary, -and patients seldom reach adult 
 life. Lovett and Nicholls found it associated with changes in the 
 adrenals (1906). Naturally the long bones of the limbs are those 
 most often fractured, usually from no recognizable injury; union 
 occurs without difficulty, but usually with deformity owing to the 
 
DYSTliUl'lllES OF HONE 417 
 
 frcciiK'iit lack of splinting. The calvaria may remain membranous 
 throutrliout, or scattered hone islets may (IcNcIop. 
 
 Fig. 423. — Extreme bone atrophy, occurring in hereditary syphilis, in a girl, aged 
 eighteen years, who had not walked for five years. The continuity of the tibia is lost, 
 that of the fibula preserved (concentric atrophy). The tarsal bones and articular 
 extremities of the tibia and fibula show eccentric atrophy. Episcopal Hospital. 
 
 Achondroplasia. — Achondroplasia is a congenital affection in 
 which the epiphyses of the long bones become ossified abnormally 
 early, preventing growth of these bones in length, and giving these 
 patients a topical appearance: normal-sized body, with dwarf-like 
 extremities. The calvaria (of membranous development) usually is 
 unaffected. Shattuck classes it as a para-cretinous condition, and 
 found it associated with changes in the thyroid. 
 
 Rachitis. — This is a disease apparently dependent on malnutrition, 
 
 and having its chief manifestations in the osseous system. It begins 
 
 almost exclusively in young children (under three years of age), 
 
 but seems never to be congenital. The patients usually are not 
 
 27 
 
418 
 
 DISEASES OF BONE 
 
 breast-fed, but have been brought up on improper milk mixtures. 
 The osseous changes occur chiefly in the epiphyseal cartilages, and 
 consist in irregular over-growth of cartilage cells; some of these car- 
 tilaginous islets may be displaced into the metaphysis, and cause 
 subsequent trouble (see Multiple Cartilaginous Exostoses, p. 443). 
 Though the cartilage cells form osteoid tissue, there is deficient depo- 
 sition of lime salts, and such as are deposited may be removed by 
 lacunar resorption, resulting in marked osteoporosis. When the 
 disease passes off, after lasting from three to five years, the bone 
 becomes hard, dense, and eburnated, and deformities developed 
 during the earlier period become permanent. 
 
 Symptoms. — Early in the disease, attention may be drawn to the 
 infant on account of constant fretfulness, sweating about the head, 
 backwardness in walking or even crawling, inability to sit up alone, 
 delayed dentition, etc. In extreme cases the limbs are very painful, 
 and pseudo-paralysis may be present. When ph\sical signs begin 
 
 to develop, among the most constant 
 and conspicuous is enlargement of the 
 epiphyseal cartilages (Fig. 424), ap- 
 preciable especially at the wrist, ankle- 
 and costo-sternal joints, the deformity 
 in the last named situation being 
 
 P'iG. 424. • — Rachitis. Age five 
 years. Scarcely able to walk alone. 
 Children's Hospital. 
 
 Fig. 425. — Rachitis. Age two years. 
 Showing how bow-legs develop from persist- 
 ent malposition. Children's Hospital. 
 
 called the "rachitic rosary." The head appears square, the forehead 
 is high, and the fontanelles remain open to the third or fourth year. 
 The thorax may present a transverse depression (Harrison's groove, 
 1820) from the constant tug of the diaphragm on the softened ribs. 
 The child is "pot bellied," and there may be a long, rounded kyphosis 
 of the spine, which disappears completely on hyperextension; the spine 
 
RACHITIS 
 
 419 
 
 is iKnvluTc rifijicl. Various (loformities of the extremities develoj), due 
 to malposition and pressure (Fi^- 425). " Kjioek-knee" or (jcnn, vdhjiim 
 usually is due to changes in the lower femoral e])iphysis, with over- 
 growth of the internal condyle, increasing the normal outward deviation 
 of the leg; "out-knee" or genu varum is a less usual deformity than 
 "l)ow-legs," in which the main deformity is in tlie leg hones. Knock- 
 knee and how-leg may coexist (Fig. 420), generally due to the mother 
 carrying the child constantly on the same 
 arm (that side on which knock-knee 
 develops) instead of alternating on the 
 right and left. Anterior curvafure of the 
 tibiw is a conspicuous deformity, but 
 very slightly disabling. Rachitic coxa 
 vara is one of the less usual deformities. 
 Rachitic (h'Jormity of the iwlvis may in- 
 terfere with parturition. 
 
 Treatment. — In early stages constitu- 
 tional treatment is most important, and 
 may be successful in preventing develop- 
 ment of deformities. The diet must 
 be regulated, and as soon as the child 
 can be weaned, a generous mixed diet, 
 with plenty of vegetables, is preferable 
 to continuance with milk; of all tonics, 
 exclusive of fresh air, cleanliness, and 
 sunlight, which of course must be pro- 
 vided, none is so good as cod liver oil; 
 this (not an emulsion, but the pure 
 Norwegian oil) may be given three 
 times daily in doses from 30 minims 
 up to any quantity that can be ab- 
 sorbed. In the very exceptional cases 
 in which this is not tolerated, the syrup 
 of the iodide of iron may be substituted; 
 and in many cases phosphates should 
 be given in addition. Locally, begin- 
 ning deformity in the limbs may be overcome by daily gentle manip- 
 ulation in the mildest cases; or by splinting, or the use of gypsum 
 cases renew'ed every few weeks with the legs in a corrected position. 
 The use of braces, which is preferable when the patient can afford 
 to purchase them, usually will overcome slight deformities within 
 eighteen months or two years, if applied while the bones are still soft 
 (before the age of two years and a half). Bow-legs show a greater 
 tendency to spontaneous cure, and improve much more rapidly under 
 treatment by braces than do knock-knees. Good types of braces are 
 shown in the accompanying illustrations (Figs. 427 and 428); the 
 modus 02)era7idi of braces is not to overcome the deformity forcibly, 
 but to prevent growth in other than the proper direction; they 
 
 Fig. 426. — Rachitic legs: 
 knock-knee on right, bow-leg on 
 left, from being carried con- 
 stantly on the mother's right arm. 
 Orthopaedic Hospital. 
 
420 
 
 DISEASES OF BONE 
 
 require constant repair and readjustment, and the surgeon should see 
 that they are in repair and properly adjusted every third or fourth 
 week. Usually they need not be worn at ni^ht in bed. 
 
 After the age of three years, and occasionally earlier, very little 
 improvement can be expected from conservatixe measures, and an 
 operation should l)e undertaken. Manual correction may be attempted 
 by Anzoletti's method (1909): plaster of Paris is moulded very 
 accurately to the extremity, from beyond the toes well up to the 
 groin, so as to prevent all motion, and the patient is kept in bed on 
 low diet for four or five weeks, so as to promote bone atrophy; at 
 the end of this time the gypsum is removed, and the softened bones 
 sometimes may be bent in the hands to the desired shape without 
 
 Fig. 427. — Bow-leg braces. Pads over 
 internal condyles and internal malleoli, 
 with leather apron over apex of de- 
 formity. Orthopaedic Hospital. 
 
 Fig. 428. — Knock-knee braces. Pads 
 over internal condyles and internal malleoli. 
 Orthopaedic Hospital. 
 
 anesthetizing the patient. Plaster of Paris is then applied in an 
 over-corrected position, and the patient encouraged to walk about, 
 being fed up, and given cod liver oil; at the end of four or five weeks 
 the bones will be hard enough to go without support. I have tried 
 the method several times, but think it suitable onl\' for acute cases, 
 especially those of bow-legs; in cases of long duration it is better 
 to resort to osteoclasis or osteotomy. Osteoclasis, or breaking the 
 bone, is accomplished by use of the osteoclast (Fig. 429), the patient 
 being anesthetized; the limb is then put \\\i in plaster of Paris in 
 over-corrected position, and is treated as a fracture. Osteotomy, or 
 division of the bone by an osteotome (Fig. 451,4), which may be 
 described as a chisel bevelled on both edges, so as to cut straight 
 
RACHITIS 
 
 421 
 
 ahead, is i\ouv tlir()U<!;li a minute incision wliicli divides the j)eri- 
 osteuni. The (»sti'(»t()ine is introchieed throufih the periosteum, is 
 tur-iied ti-ansNcrselx to the loiii;' axis of the Hml>, and is (hi\(ii throu,<;li 
 
 Fig. 42(». — Hopkins's osteoclast. Urthopii'flic Hosi)ital. 
 
 the bone by a mallet in such a way as to divide it trans\ersely all 
 except a few fibres at the further side; several cuts in the bone (all at 
 the same level) may be necessary, but they are all made through the 
 one skin incision, making practically a subcutaneous operation. The 
 
 Fig. 430. — Knock-knees, osteotomy of 
 both femurs. (See Fig. 431.) Ortho- 
 paedic Hospital. 
 
 Fig. 431. — Result of osteotomy of femurs 
 for knock-knees. Orthoptedic Hospital. 
 
 remaining bone fibres are then fractured by hand, the incision closed 
 with one suture, and the limb is put up in plaster of Paris in an over- 
 corrected position. For knock-knee the osteotomy is done a finger's 
 
422 
 
 DISEASES OF BONE 
 
 breadth above the epiphyseal Une of the femur, usually on the outer 
 side of the bone (Figs. 430 and 431); for bow-legs it is done at the 
 
 Fig. 432. — Bow-legs, osteotomy of 
 both tibiae. (See Fig. 433.) Ortho- 
 pjedic Hospital. 
 
 Fig. 433.— After osteotomies for bow-legs. 
 Orthopaedic Hospital. 
 
 apex of the deformity, usually only the tibia being di\ided, the fibula 
 bending or being broken by hand (Figs. 432 and 433). The correc- 
 
 Fig. 434. — Anterior curvature of tibite 
 in rachitis. (See Fig. 435.) OrthopEedic 
 Hospital. 
 
 Fig. 435. — Anteriur cur\ature of tibite 
 after osteotomy. Orthopaedic Hospital. 
 
 tion of anterior curvature is more difficult (Figs. 434 and 435). The 
 patient is not allowed to walk for six or eight weeks. 
 
OSTEITIS DEFORMANS 
 
 423 
 
 Scurvy. Scurvy, which may compHcatc rachitis or occur lude- 
 pcndcutly, should' he hornc in mind as a possible cause of symptoms 
 of bone disease in infants. Tenderness of shafts of long hones, with 
 skiagraphic evidences of subperiosteal hemorrhages, in association 
 with other scorbutic symptoms, should make one suspicious of this 
 condition. The diagnosis from tuberculous or subacute septic osteo- 
 myelitis is not always easy. Constitutional anti-scorbutic treatment 
 is indicated. 
 
 Fig 4.36 —Osteomalacia (five years' duration) in a patient, aged seventy-eight years. 
 Confined to bed for six months. Fracture of right femur occurred the day before the 
 photograph was taken, and death from asthenia two days later. Dr. F. W . .Sinkler s 
 case. Episcopal Hospital. 
 
 Osteomalacia.— Osteomalacia, or softening of the bones, is an 
 affection occurring mostly in women, often in those who have borne 
 several children in rapid succession. It is believed to be associated 
 with ovarian disease. Scarcely ever does it occur before puberty. 
 Deformity is progressive and marked, involving the pelvis, the 
 vertebrarcolumn, and later the extremities. "Spontaneous fracture" 
 (Fig. 43G) may occur, but is not frequent. The disease has been 
 treated by oophorectomy, but some surgeons (Bastianelli) claim that 
 the benefit from such operations has been due to the chloroform inha- 
 lation used for anesthesia; and they now induce such anesthesia 
 without doing an operation (W. J. Mayo, 1910). According to :Mayo, 
 also, different Italian observers have found an identical and specific 
 diplococcus in the periosteum in this disease, in rachitis, and in osteitis 
 deformans; when a culture of this diplococcus was injected into rats 
 it produced rachitis in the very young animal, and osteomalacia in 
 adult rats. The relation of thyroid diseases to osteomalacia is not 
 
 Osteitis Deformans {Paget' s Disease of the Bones, 1876) occurs in 
 adult life, patients usually not applying for treatment until well 
 past forty years of age. It runs a very chronic course, lasting many 
 years, and"^ growing progressively worse, though intermissions and 
 exacerbations may occur. It is characterized in its earlier stages 
 by osteoporosis, causing flexibility and deformity of the bones; but 
 later the bones hypertrophy and become markedly thickened. Frac- 
 ture is rare. The lower extremities are affected earliest, resulting 
 
424 
 
 DISEASES OF BONE 
 
 in general outward and anterior bowing of the knees and legs; the 
 spine shows a long, rounded kyphosis, and the calvaria becomes very 
 much thickened. At times the bones are very painful, but often 
 progressive enlargement of the head is what first calls the patient's 
 attention to his condition. Eventually loss of height is observed, 
 
 the attitude resembling that of anthropoid 
 apes, with bowed head, disproportionately 
 long arms, and a waddling gait (Fig. 437). 
 Some weakness and stiffness usually exist, 
 but death occurs only from intercurrent dis- 
 ease, usually pulmonary, or from advanced 
 arteriosclerosis which is a prominent feature 
 of the malady. 
 
 Treatment. — Treatment is chiefly hygienic 
 and dietetic. Thymus or thyroid extract 
 may be of value. Pain may be relieved by 
 application of proper orthopedic apparatus. 
 Hypertrophy of Bone. — This may be com- 
 pensatory, as when one of two parallel bones 
 is removed for disease, the other may become 
 hypertrophied. Or it may be the result 
 of chronic irritation, as in thickening of 
 a tibia underlying an old leg ulcer. In- 
 crease in thickness and weight is commoner 
 than increase in length, though the latter 
 occurs to a marked degree in some ampu- 
 tation stumps, (p. 200) ; sometimes, too, after 
 fracture or tuberculous or inflammatory 
 lesion of bone, actual increase in length 
 may occur, or at least the affected bone 
 may grow faster than the corresponding 
 bone on the other side of the body. 
 
 Leontiasis Ossea (Virchow, 1865) is a 
 disease usually arising in youth, charac- 
 terized by hypertrophy of the face bones, 
 giving the face a leonine expression, due 
 to the gradual obliteration of its features. 
 The foramina in the base of the skull may be narrowed, causing 
 exophthalmos, blindness, and paralysis of the various cranial nerves. 
 Hypertrophy of the calvaria causes pressure on the brain, with 
 headaches, convulsions, etc. No treatment is of avail. 
 
 Acromegaly (P. ]Marie, 1886) is a disease of youth or early adult 
 life, characterized by hypertrophy, enlargement and thickening of 
 the apices and extremities of the skeleton — fingers, toes, chin, nose, 
 etc.; while similar soft tissues also may enlarge — lips, tongue, ears, 
 and even penis and clitoris. A rounded kyphos develops in the 
 dorsal spine. Headache is the chief subjective s^■mptom. The 
 disease often is caused by changes, usually neoplastic, in the hypo- 
 
 I'lG. 437. — Osteitis defor- 
 mans (Paget's disease) in a 
 patient, aged seventy-two 
 years. Duration twelve 
 years. Orthopsedic Hospital. 
 
INFECTIONS OF BONE 
 
 425 
 
 pliysis (•(Tcl)ri; n skiagrapli may (lemonstratc (Milargcincnt of the sella 
 tureica, and pressure syini)tonis from hypophyseal growth may 
 develop later. Treatment by pineal, thyroid, thymus, or other 
 extracts may he tried, but tlie only hoi)e of cure consists in removal 
 of the hypophysis (see p. oS4). 
 
 INFECTIONS OF BONE. 
 
 Infection of a bone usually occurs through the blood-stream, some 
 locus uiinori.s' rcsLstcntia', generally due to injury, determining locali- 
 zation of the infection. Those who have a general blood-infection 
 (furunculosis, typhoid fever, syphilis, tuberculosis, etc.), therefore, 
 are predisposed to bone infection. Infection of bone also occurs 
 in compound fractures, but as in these the products of inflammation 
 are readily discharged from the broken surfaces and through the 
 wound of the soft parts, the disease seldom assumes such .serious 
 proportions as when infection arises in the unbroken bone; in the 
 latter instance the very structure of the bone prevents swelling, so 
 that strangulation and necrosis occur very early. 
 
 Acute Periosteitis. — Acute periosteitis rarely occurs as an isolated 
 affectioji; in almost every case there are also osteitis and osteomye- 
 litis, and it is probable that the in- 
 fection is localized first in the medulla, 
 and is propagated to the periosteal 
 surface of the bone through the Haver- 
 sian canals. In convalescence from 
 typhoid fever, however, subperiosteal 
 abscess may occur, and in most such 
 cases there is no appreciable involve- 
 ment of the medulla, and at most 
 only a superficial caries of the cortex. 
 The lesion occurs of tenest in the long 
 bones and the ribs; relief of symptoms 
 (pain, tenderness, swelling, fever, etc.), 
 and rapid cure usually follow incision 
 of the periosteum and scraping the 
 carious bone (Fig. 438). 
 
 Chronic Periosteitis. — Chronic peri- 
 osteitis is a frequent lesion, occurring 
 in many of the dystrophies already de- 
 scribed, or as the result of contusions 
 of bone, from chronic inflammation of 
 overlying soft tissues, and in chronic 
 infections, especially syphilis (Fig. 
 400). The long bones are most often 
 affected: the periosteum is raised 
 from the shaft by the formation of new bone, and the resulting 
 deformity may be very evident on inspection. Distinct periosteal 
 
 Fig. 438. — Periosteitis of left 
 tibia nine months after typhoid 
 fever. Age nine years. Episcopal 
 Hospital. 
 
426 DISEASES OF BONE 
 
 nodes may form, or the thickening may be diffuse. Usually there is 
 a good deal of aching, but no very acute pain; the osteoscopic (bone- 
 tiring) pains become worse after exertion and when the warmth of 
 bed induces hyperemia of the diseased parts. The treatment is 
 much the same as for syphilitic periosteitis (p. 442). 
 
 Osteitis. — Osteitis scarcely ever occurs as a recognizable affection 
 apart from accompanying osteomyelitis. 
 
 Osteomyelitis. — This is an acute septic infection of bone marrow, 
 usually due to the Staphylococcus aureus, and affecting mostly the 
 long bones of the extremities, especially the tibia, femur, and ulna, 
 in their juxta-epiphyseal portion, which is named by Kocher the 
 metaphysis. It occurs almost exclusively in children from six to 
 sixteen years of age, and often follows slight trauma, or exposure 
 to cold and wet, as in frequent swimming expeditions. Predisposing 
 causes are malnutrition, convalescence from the exanthemata or other 
 general infections. 
 
 Owing to the dense bony case in which the inflammation occurs, 
 it is extremely rare for an abscess to form; instead a true phlegmon 
 of bone results, infection spreading up and down the medulla. The 
 cortex is affected secondarily, and in most cases periosteitis results 
 from transmission of infection through the Haversian and \'olkmann's 
 canals. The process rarely extends into the joints, even in adults, 
 and in children nearly invariably is arrested at the cartilage of the 
 epiphyses. Swelling being impossible, the medullary tissues become 
 strangulated, and death of the bone in large masses follows (necrosis), 
 its extent depending on the destruction of the marrow cells within, 
 and on the amount of separation of periosteum on the surface. Some- 
 times the entire shaft of the bone becomes necrotic, is spontaneously 
 detached at its epiphyses, and floats in pus beneath the unruptured 
 periosteum. Usually, however, before this stage is reached drainage 
 is instituted by operation, or the periosteum is perforated by the 
 pus with formation of a parosteal abscess in the soft tissues. The 
 periosteum is raised from the cortex, and new subperiosteal bone is 
 formed; this at first is plastic but later becomes sclerotic and is known 
 as the invulucrum; and such portions of the bone marrow as survive 
 form new bone within, so that eventually the necrotic portion of 
 bone, known as a sequestrum, is more or less completely surrounded 
 by new-formed bone but still communicates with the surface through 
 orifices in the involucrum known as cloacoB, and through these a 
 discharge of pus continues. Several sequestra may form, each having 
 its own cloaca or cloacse, and discharging on the skin surface through 
 numerous sinuses (Fig. 439). When this stage of the disease is 
 reached, it assumes a chronic form usually described by the term 
 Necrosis (p. 431). 
 
 Symptoms. — These are both general and local, the former often 
 so over-shadowing the latter that without attenpon to the history 
 and careful physical examination the disease has been mistaken for 
 toxemia resulting from typhoid fever, pneumonia, meningitis, etc. 
 
OSTEOMYELITIS 
 
 427 
 
 The disease may be usiiered in by a cliill, with sudden rise in tempera- 
 ture to 10;')° F. or hi<^her, the child appearing very ill and making 
 little complaint of the extremity afiectecl. In these hyperacute cases 
 death from septicemia may occur within a day or two in spite of 
 active treatment. In most cases, however, the affected limb becomes 
 painjul, helpless, and swollen; redness may not be evident. Tender- 
 ness is extreme, extending throughout the shaft of the affected bone, 
 but most intense at one spot. Indeed, tenderness usually is so great 
 
 N^.r'- 
 
 
 ^^ 
 
 '■■:■! 
 
 Fig. 439. — Diagram of changes occurring in a case of acute osteomyelitis of the tibia. 
 In the first figure, there is diffuse suppuration in the medulla of the diaphysis. In 
 the second figure, the products of inflammation are seen, filling the space between the 
 cortex and the periosteum. In the third figure, new subperiosteal bone has been formed, 
 and within this involucrum is seen a large sequestrum, surrounded by pus, which dis- 
 charges through openings in the involucrum, known as cloaca. In the fourth figure, 
 only a small cortical sequestrum remains, the involucrum has become very dense, and 
 the medullary cavity is replaced by eburnated bone, (de Quervain.) 
 
 as absolutely to prevent palpation at the seat of greatest disease. 
 Even if the remainder of the shaft be not tender to palpation or 
 tappng, prolonged gentle pressure even at a distance will eventually 
 and suddenly become acutely painful; this is a valuable diagnostic 
 point (Nichols, 1907). The disease is often mistaken for acute rheu- 
 matic arthritis, with most disastrous results; but in osteomyelitis the 
 joints are not involved, while the bones are; and multiple lesions, 
 common in acute rheumatic fever, are rare so early in the course of 
 
428 DISEASES OF BONE 
 
 osteomyelitis, though quite frequent hiter. Tlie distinction between 
 deep-seated suppuration of bone, and serous joint efiusion should 
 not be diffieult if physical examination is thorough. The mistake is 
 most apt to occur in the case of bones which are not subcutaneous 
 (femur, radius, humerus), but ignorance and carelessness may err 
 even in the case of the tibia or ulna. At later stages, if the patient 
 survives, edema of the skin, with redness, and even fluctuation, 
 make a mistake absolutely unpardonable. Throughout the course 
 of the disease the surgeon should be on the lookout for secondary 
 invasion of other bones, which is often overlooked for some days, 
 owing to a subacute onset. 
 
 Fig. 440. — Skiagraph of acute osteomyelitis of femur; age seven years; treated 
 at home for "typhoid fever" for four weeks. Episcopal Hospital. 
 
 Treatment. — As soon as the diagnosis is made, the bone should be 
 opened. Delay even of a few hours is dangerous in very acute cases, 
 leading to widespread necrosis, pyemia, and multiple secondary foci of 
 osteomyelitis in other bones. In a case of which I have cognizance, 
 the patient was treated during four weeks for typhoid fever, with the 
 result that not only was he gravely ill for many months with pyemia, 
 but he lost his entire ulna, and developed secondary lesions in one 
 tibia, and both femora (Fig. 440). The patient should be anesthe- 
 tized, the limb elevated until bloodless, and an Esmarch band applied 
 well above the diseased area; a free incision is then made dividing 
 the periosteum where subcutaneous or after exposure through the 
 proper intermuscular space. Usually the periosteum is found more 
 or less widely detached from the cortex by pus; the cortex then may 
 look white and dead, but generally a few minute bleeding-points 
 (Volkmann's canals) may be seen. If the periosteum is detached 
 from the cortex throughout, and the shaft is loosened at its epiphy- 
 seal attachments, the entire shaft may be removed, either in one 
 
OSTEOMYELITIS 
 
 429 
 
 piece, or l)y wreiichiiig each ciul free after sawiiiji; the h(jiie across 
 its centre; in the case of tlie femur and liurnerus, however, where no 
 parallel hone exists to act as splint, it will })e better, even under 
 these circumstances, to leave the shaft in place until an involucrum 
 has formed dense enough to maintain the form of the limh. Where 
 the i)eri()steum is only partly detached from the hone, or where the 
 infection has not yet extended from the marrow out through the 
 cortex, the cortical bone may appear normal; but in all cases the 
 
 surgeon shonld open the viedulla to 
 provide drainage. The periosteum 
 should be carefully detached from 
 a sufficient area, and the medulla 
 exposed by trephine or g(^uge and 
 mallet. The marrow usually is found 
 softened, grayish yellow, or even 
 purulent; but failure to find frank 
 pus by no means indicates that septic 
 osteomyelitis is absent. If the oper- 
 ation is done sufficiently early the 
 inflammation may not have progressed 
 to the stage of suppuration; and in 
 certain cases of subacute infection 
 (perhaps tuberculous), there is what 
 is known as albuminous osteomyelitis 
 (Oilier, 1S72), the exudate being serous 
 or at most sero-purulent. In such 
 cases, or if the diagnosis is doubtful. 
 
 Fig. 441. — Specimen of tibia ex- 
 cised for osteomyelitis; below is seen 
 the trephine opening made for ex- 
 ploration; above, the large opening 
 made by gouge and mallet. Finally 
 the entire diaphysis was excised. 
 Episcopal Hospital. 
 
 Fig. 442. — Deformity following excision of 
 radius twenty-five j-ears ago for osteomyelitis; 
 useful hand ; man works as laborer. Episcopal 
 Hospital. 
 
 the marrow may be exposed by drill holes. If the medulla is found 
 widely infected, a second button of bone may be removed at a dis- 
 tance from the fir.st, to determine the extent of medullary implication; 
 and the intervening bone may then be removed by gouge and mallet, 
 cutting a long gutter in the cortex, and widely exposing the medulla. 
 It never is proper to curette the marrow or attempt its removal in 
 
430 
 
 OSTEOMYELITIS 
 
 any way, any more than it is proper to curette an acute phlegmon of 
 the soft parts (p. 51); it is probable that all the marrow cells are 
 not destroyed, and such as still are living are very important agents 
 in forming new cortical bone. The periosteum alone is not always 
 capable of forming an entire new shaft. In exceptional cases total 
 resection of the diaphysis, even if this is not wholly necrotic, may 
 be done when a parallel bone exists to act as splint, if the osteo- 
 
 FiG. 443. — Deformitj- from excision of tibia for osteomyelitis. Operation two years 
 ago. Xow fourteen years old. Ankylosis of knee. Only upper and lower epiphyses of 
 tibia remain, with about three inches of shaft above malleolus. Gannot stand on leg. 
 Episcopal Hospital. 
 
 myelitis is so widespread as to render probable total necrosis later, 
 or if the patient's condition is so septic that prompt convalescence 
 is demanded (Fig. 441 ) ; but such removal often leaves a deformed 
 (Fig. 442) or helpless limb (Fig. 448), which later may require an 
 orthopedic operation (p. 504). In the case of the humerus and femur, 
 where the disease is not very acute, it is sufficient to trephine the 
 bone at the limits of inflammation, and pass a drainage tube from 
 one opening to the other through the medulla. If guttering has been 
 
 Fig. 444. — Granulating wound two months after guttering (evidement) of tibia 
 for osteomyelitis. Children's Hospital. 
 
 done, the marrow cavity is firmly packed with iodoform gauze, the 
 wound is left widely open, and is allowed to heal by granulation (Fig. 
 444). If the entire diaphysis has been removed, the same course may 
 be pursued, or the periosteum may be sutured lightly together, 
 obliterating the cavity, as advised by Nichols (1904). 
 
 If operation has been done early enough, necrosis of the shaft may 
 not occur, and permanent healing will follow the primary intervention. 
 
NECROSIS OF BONE 
 
 431 
 
 In most cases, however, portions of the cortex become necrotic, arc 
 ext'oHated as seqnestra, and may require subsequent operation for 
 their i-cnio\al. 
 
 Chronic Osteomyelitis. — ^Tliis is rarer tlian tlie acute form of the dis- 
 ease and is due to a less virulent infection. The bone is infiltrated 
 witli purulent material, its lime-salts are more or less al)sorbed and 
 the narrow cavity obliterated. Treatment. — Free drainage should be 
 j)rovided, and, if possible, all the dis- 
 eased bone should be gouged away. _ .i-1?'Jt 
 Recurrences are frequent unless radical 
 operation is done. Eventually hyper- 
 trophy, sclerosis, and eburnation occur. 
 
 Necrosis. — Necrosis is the term ap- 
 plied to the chronic stage which succeeds 
 acute or subacute osteomyelitis. It 
 implies the presence of a sequestrum, 
 more or less detached; of an involvcrum, 
 more or less developed; and of cloacce, 
 usually communicating wuth the surface 
 of the limb by sinuses through which 
 bare bone may be felt. Caries is that 
 condition of bone comparable to an ulcer 
 of the soft parts, there being no actual 
 sequestrum (slough), but only death of 
 bone in molecular masses. It occurs 
 chieflv in tuberculous bone disease 
 
 
 V, 
 
 
 W.W 
 
 Fig. 445. — Cortical sequestra following osteo- 
 myelitis of femur. Episcopal Hospital. 
 
 FicJ. 446. — -Necrosis of hum- 
 erus, showing tubular sequestrum, 
 involucrum, and cloacse. Os- 
 teoporosis above. Episcopal Hos- 
 pital. 
 
 (p. 439). A sequestrum may be due to necrosis of the superficial 
 cortical layers (Fig. 445), or there may be a total or "tubular" seques- 
 trum (Fig. 446) The superiosteal bone is soft and plastic when 
 newly formed, and possesses great powers of regeneration; if, how- 
 ever, a sequestrum remains beneath it long enough, the involucrum 
 
432 
 
 DISEASES OF BONE 
 
 gradually loses its regenerative powers, and becomes dense and 
 sclerosed; sometimes so dense that the finest steel makes no impres- 
 sion on it. Therefore, it is better, whenever possible, to remove 
 
 I'"ir.. 447. — Skiagraph of necrosis of til)ia, showing large sequestrum within 
 involuoruni. Ei>isco|>al Hospital. 
 
 Fig. 448. — Sequestrum of radius ulcerating out eleven months after compound 
 comminuted fracture. Episcopal Hospital. 
 
 sequestra while the involucrum is still plastic, so that the cavity 
 left Avill be filled up promptly by periosteal proliferation. This stage 
 usually ceases about two or three months after the primary infection. 
 
M'J('lil)6l:S OF HONE 
 
 433 
 
 Tlio jilastic condition of tlu* snhporiosteal hone may he (k'tcnnincd 
 
 hy sti{'kin<;' a noedk' thr()n<i;h it, close to a siiuis, when (•raekHn<; 
 
 will occur, and the needle will he 
 
 arreste«l hy the necrotic shaft under- 
 neath; or it may he ix)ssihle to see the 
 
 new-formed hone in a skiagraph (Fif,'. 
 
 447). If there is a parallel hone pres- 
 ent, as in the forearm and leg, removal 
 
 of the sequestra may he imdertaken so 
 
 soon as the patient convalesces from 
 
 tlu> first operation, and prompt regen- 
 eration e\en of an entire shaft may 
 
 he anticipated; but when the femur 
 
 or humerus is affected, it is better to 
 
 delay secondary operation until a fairly 
 
 strong involucrum has formed. This is 
 
 about two or three months after the 
 
 onset of the disease; the strength of 
 
 the involucrum may he determined by 
 
 skiagraphy, and its total thickness should 
 
 approximate half that of the normal 
 
 bone. In some cases sequestra will 
 
 work themselves loose, and eventually 
 
 may be discharged spontaneously (Figs. 
 
 448 and 449), but this may require 
 
 many years, and in most cases ulti- 
 mate cure is much accelerated by 
 
 operation. 
 
 Sequestrotoniy, as the operation for 
 
 the removal of sequestra is called, is 
 
 done under Esmarch anemia : a rubber 
 
 bandage is applied from the fingers or toes to above the upper limit 
 
 of disease (Fig. 4.30), thus removing most of the blood from the limb; 
 
 an Esmarch band is 
 then applied just above 
 the termination of the 
 elastic bandage, which 
 is then removed, leav- 
 ing a bloodless field for 
 operation. This is im- 
 portant because hem- 
 orrhage from the in- 
 volucrum and medulla 
 may be free, and unless 
 the wound is dry it is 
 difficult to distinguish 
 
 dead from living bone. The limb is then incised, including as many 
 
 sinuses as possible in the line of incision, or excising the scar of previous 
 28 
 
 Fig. 449. — rhronic osteomyelitis 
 of femur ; age forty-throe years, onset 
 seven years ago. No symptoms for 
 several years until a few weeks ago, 
 when a sequestrum began to work 
 loose; sequestrum extracted through 
 sinus, which promptly healed. Epis- 
 copal Hospital. 
 
 Fig. 450. — Rubber bandage applied for bloodless opera- 
 tion. The Esmarch band is then applied above the knee, 
 and the rubber bandage is removed from the leg, ex- 
 posing the seat of operation (sequestrotoniy of tibia). 
 Episcopal Hospital. 
 
434 
 
 DISEASES OF BONE 
 
 operation. If the subperiosteal bone is still plastic it is incised with a 
 heavy knife and carefully reflected from the underlying necrotic shaft, 
 whicii is then removed piecemeal or in mass. If a dense involucrum is 
 present, it is searched for cloacae, and the location of sequestra deter- 
 mined, enough of the overlying bone being removed to permit of their 
 removal ; they are more apt to be completely detached from surrounding 
 
 Fig. 451. — Instruments for operation on bones: 1, wooden mallet; 2, Hey's saw; 3, 
 chisel; 4, osteotome; 5, Volkmann's sharp spoon or bone curette; 6, Jones's gouge; 7, 
 gouge bevelled on its convexity; 8, thumb gouge; 9, gouge forceps; 10, 11, sequestrum 
 forceps; 12, burr. 
 
 healthy bone than at an earlier stage. When the sequestrum is not 
 completely detached, suspected bone should be removed by gouge 
 and mallet until healthy bone is reached. This is known by the 
 fact that minute blood spots on the bone (Haversian canals) cannot 
 be washed away in living bone, whereas rinsing a chip of dead bone 
 in water will remove all blood from its surface. 
 
 If the operation is done before sclerosis of the involucrum the cavity. 
 
NECROSIS OF BONE 
 
 435 
 
 if small, may hv allowod to fill with blood-dot, and this prohahly 
 will he coiiviTtcd into hony tissue hy suh-periosteal proliferation 
 (Fif^. 452). When, however, the iinoluerum is dense, any ea\ity left 
 will remain a eavity, unless filled with some substance to stiniulate 
 ossification. Probal)ly the best substance for such purposes is the 
 
 Fig. 4.52. — Skiagraph showing involucrum 
 of ulna, after removal of sequestra. Note 
 numerous cloacse. Age fourteen years. Epis- 
 copal Hospital. 
 
 Fig. 453. — Iodoform boiie-wax in 
 cavity of tibia (plombage) . Episcopal 
 Hospital. 
 
 iodoform bone wax of Mosetig-Moorhof (1903): iodoform, ()0 parts; 
 spermaceti and oil of sesame, each 40 parts. This is heated to 100° C. 
 while being mixed, and again heated to 50° C. before being poured 
 into the bone cavity. Such an operation is termed plombage (Fig. 
 453). I have used as much as three ounces of this wax at one time 
 
436 
 
 DISEASES OF BONE 
 
 (in a girl of seventeen years), but others have reported symptoms 
 of iodoform poisoning from less quantities. The best results follow 
 when the cavity is dried and sterilized by a hot air blast before pouring 
 in the wax; or by the actual cautery, taking care only to sear and 
 not to char the bone. If this cannot be done, the cavity may be 
 swabbed out with strong antiseptics and dried with sterile gauze. 
 In these chronic cases there is only an attenuated infection. The 
 soft tissues are sutured tight over the wax as it cools, no drainage 
 being employed; and though some of the wax may be discharged 
 eventually through a sinus, convalescence is much less tedious than 
 if no bone filling had been employed. Beck's bismuth paste (p. 484) 
 may be employed in small quantities instead of iodoform bone wax, 
 but is less suitable. In cases where the cavity left is exceedingly 
 large, it is better to resort to the old operation of evidenient, in which 
 the entire anterior and most of the lateral walls of the involucrum 
 
 Fig. 454. — Acute epiphysitis of left humerus, 
 upper end ; age eight months. Admitted with diag- 
 nosis of scurvy. Temperature rose to 105° F., 
 and at operation epiphysis was found separated. 
 Recovery. Children's Hospital. 
 
 Fio. 455. — Diagram showing 
 the relation of the upper epiphysis 
 of the humerus to the shoulder- 
 joint. 
 
 are removed by gouge and mallet, so that only a superficial trough 
 remains representing the posterior wall of the involucrum, thus 
 allowing the soft parts to grow down and across the cavity (Fig. 444), 
 which is packed with gauze. Though healing may take a year or 
 more, the cure eventually is complete. Neuber (1890) tried to hasten 
 recovery by nailing flaps of soft tissues in the gutter left by cvideinent. 
 Acute Epiphysitis. — While in children osteomyelitis is apt to begin 
 and to manifest its greatest intensity in the metaphysis, in infants 
 it occurs almost exclusively in the epiphysis (Fig. 454), and owing 
 to certain special features requires separate mention. The condition 
 frequently is overlooked, from neglect of physical examination; and 
 the closeness of a lesion to a joint (the shoulder and hip are especially 
 liable to the disease) may render it likely to be confused with acute 
 rheumatic arthritis or joint-injury; indeed, as the epiphysis becomes 
 detached from the shaft quite early in the disease, the resemblance to 
 fracture is considerable. Infection of the joint is frequent, owing to 
 
TUBEliCl'LOSrS OF HOSE 437 
 
 tlie i)()siti()ii of the cjiipliyseal line which even at the shoulder is 
 l)artly iiitra-articiihir (Fig. 4"),")), thus alVordiufj; scarcely any chance 
 for extra-articular drainage. 
 
 Treatment.^Treatment consists in early incision, exposing the 
 sei)tic focus with curette, and draining the cavity with gauze. If 
 pyarthrosis develops, the joint also should be drained. Deformity 
 from interference with growth, flail-joint, or i)athological luxation 
 (especially at the hip) may follow. Ankylosis is rare. 
 
 Bone Abscess.— As a result of osteomyelitis a residual abscess 
 (]). SO,")) may form in bone, most frequently in the tibia {Brodies 
 abscess, 1S24). \Vry rarely such an abscess may be the j^rimary 
 lesion, no diffuse osteomyelitis having preceded it; such cases usually 
 are tuberculous. A bone abscess is confined by a dense wall of 
 sclerosed bone, and may remain latent for many years, causing 
 intermittent attacks of pain and limping, and being finally roused 
 to acute stage by trauma or constitutional affection. 
 
 Diagnosis.— Tlie diagnosis depends on the history, persistent local- 
 ized bone tenderness, and .v-ray examination. 
 
 Treatment.— The dense wall should be cut away, the pus evacuated, 
 the cavity sterilized, and treated as other bone cavities (p. 435). If 
 the abscess is small, and if its outlines can be well defined by .r-ray 
 examination, it may be possible to excise it in one mass, by cutting 
 through healthy bone on all sides. 
 
 Fibrous Osteitis.— By this term is understood a condition regarded 
 by all more recent investigators as an inflammatory disease of bone 
 "in which the medullary tissue is replaced by a new formation of con- 
 nective tissue with or without cyst formation." (Bloodgood, 1910.) 
 Its relations to bone cysts and myeloma (p. 445) are not well defined. 
 It occurs in children, affects oftenest the humerus, femur, and tibia, 
 and begins insidiously; in very many cases spontaneous fracture 
 or the deformity resulting from such an unrecognized fracture is 
 what first calls attention to the condition. There may be pain and 
 increase in the size of the bone, but the disease usually is easily dis- 
 tinguished from malignant neoplasms of bone by the long duration 
 of symptoms. Unless the patient is seen for fracture, the swelling 
 and pain, neither very marked, usually exists for a year or niore 
 before the surgeon is consulted. Diagnosis is much aided by the 
 .r-ray, which wall exclude sarcomatous change, and may show cyst 
 formation. 
 
 Treatment.— The treatment consists in removal of all diseased 
 tissue h\ gouge or curette, the ca^'ity being treated as one following 
 seq nest rot omy. 
 
 Tuberculosis of Bone.— Tuberculosis rarely affects the diaphyses 
 of long bones, its lesions being confined almost exclusively to the 
 region of the epiphyseal cartilages; but in short bones (hands, feet, 
 vertebra?), diffuse medullary involvement is common. There are 
 good anatomical reasons for this. As noted in Chapter III, tubercle 
 bacilli usually find lodgement in the lymph nodes, and only when 
 
438 DISEASES OF BONE 
 
 these caseate and rupture do the })acilli escape into the })lood-streain. 
 Infection of bone, therefore, occurs through the blood, the lesion 
 being an infarct or embolus which has successfully passed through 
 the pulmonary capillaries. There are three sets of arteries supplying 
 long bones — one, the main nutrient artery, enters the diaphysis, 
 and branches in both directions; a second enters the metaphysis, 
 while the epiphyseal arteries form the third group; now all these 
 arteries send their terminal branches to the region of the epiphyseal 
 cartilage (which is bloodless), and they do not inosculate with each 
 other. It is in this region, therefore, that bacterial emboli lodge, 
 no matter by which of the three arterial systems they enter the 
 bone. In short bones, however, the main nutrient artery breaks 
 up into small branches almost as soon as it enters the cortex, and 
 tuberculous emboli are arrested in the medulla. It is denied by some 
 that trauma, in creating a locus mi nor is resisi entice, has any influence 
 in determining the localization of tuberculous foci in bone; but clinic- 
 ally it is a well established fact that any site of lessened resistance 
 is prone to invasion by tuberculosis, whether the primary change is 
 traumatic or infectious. According to Ely (1911) the reason that 
 tuberculosis develops in the neighborhood of the epiphyses, and not 
 in other regions (as the brain) which are supplied by end-arteries, is 
 because in the epiphyses the soil is suitable for the growth of tubercle 
 bacilli, while elsewhere it is not (see p. 476). If the tuberculous 
 process begins on the shaft side of the epiphyseal cartilage of a long 
 bone (i. e., in the metaphysis), the resulting lesion resembles a very 
 subacute type of septic osteomyelitis; this condition appears to be 
 more common in Great Britain and on the continent of F.urope than 
 in this country. Its existence was recognized by Volkmann in 1S79, 
 and Stiles has recently (1912) called renewed attention to it. If, 
 however, the tuberculous embolus lodges on the joint side of the 
 epiphyseal cartilage the joint is quickly invaded ; and this often occurs 
 even when the metaphysis is first involved, especially' in joints where 
 the epiphyseal cartilage is largely inside the joint capsule. 
 
 The affected area undergoes caseation, the bony framework melting 
 away in the centre, while proliferation may take place under the 
 periosteum. In favorable cases the disease may become latent, 
 by encapsulation of the tuberculous focus; or softening may extend, 
 the cold abscess may rupture into a neighboring joint (very frequent 
 in case of long bones), may work its way to the skin surface through 
 a sinuous tract, or may cause gradual expansion of the cortex, with- 
 out rupture (especially in the phalanges). Secondary pyogenic 
 infection may occur, especially after sinus formation, and an osteo- 
 myelitis originally purely pyogenic may become secondarily infected 
 by tuberculosis. For such cases more or less formal operation (seques- 
 trotomy, plombage, evidement), may be required. Joint infection 
 is so very frequent in the case of long bones (especially the femiir, 
 tibia, and humerus) that it is best to study epiphyseal tuberculosis 
 in connection with tuberculosis of joints (p. 476). This is also the 
 
TUUERCVLOSHS OF HOSE 
 
 439 
 
 case ill tlio hoiios of the carpus and tarsus. \'crtcl)ral tuberculosis 
 is considered in Chapter XVI II. 
 
 In tlie metacarpal bones and piialauges a diffuse tuberculous 
 osteomyelitis follows the arrest of tuberculous emboli, and the lesions 
 are the same in kind as, though running 
 a nuich less acute course than in pyo- 
 genic osteomyelitis. Tuberculous dactyl- 
 itis, as this form is called, occurs almost 
 exclusively in infauts and young children 
 (P'igs. 37 and 45(3) ; it may affect several 
 digits, and may be accompanied by 
 tuberculous bone disease elsewhere. 
 Caries of facial bones in infants usually 
 is tuberculous. Local rest and clean- 
 liness, and general hygienic measures 
 usually cure the- disease, though the 
 finger maj' be deformed from extrusion 
 of sequestra, ankylosis, etc. 
 
 Caries of the sJxull from tuberculosis is not very rare in adults 
 (Fig. 457). The diagnosis depends on the discovery of tuberculosis 
 
 Fig. 45G. — Tuljorculous dactjl- 
 itis, early stage; age three years; 
 duration seven months. Epis- 
 copal Hospital. 
 
 Fig. 457. — Tuberculous caries of skull. Age thirty-nine years. Phthisis for eight 
 or nine years. Present trouble began by swelling like wen, nine months ago. Six 
 months ago this ruptured and has been moist or scabbed even since. Depression in 
 bone palpable. Has another area still in wen stage, fluctuating and red. Episcopal 
 Hospital. 
 
 elsewhere in the body (notably the lung), on the exclusion of syphilis, 
 and on the chronic and indolent course of the affection. 
 
440 
 
 DISEASES OF BONE 
 
 Syphilis of Bone. — Osseous manifestations of syphilis occur late 
 in the disease, with the exception of fugacious attacks of periosteitis 
 
 llBllBiUi''^^^ 
 
 m 
 
 M 
 
 ^^^^^^^^^HH^^^ 
 
 ^^t^ 
 
 
 
 Fig. 458. — Syphilitic dactylitis. Age twenty-eight jears; duration five months. 
 Five years after chancre. Pathological fracture of jthalanx. (See Fig. 459.) Episcopal 
 Hospital. 
 
 Fig. 459. — Skiagraph of finger shown in Fig 458. (Syphilitic dactylitis.) Note 
 pathological fracture of phalanx. Episcopal Hospital. 
 
SYPIIILTS OF HONE 
 
 441 
 
 in tlic socoiulary stajje. 'V\w losioiis roscmhk' tliose oc-curring in the 
 other infectious granulomas, involving softening and caries, or pro- 
 lilcration and ehurnation. Both processes frcfjuently occur at once 
 in (lill'crt'iit j)arts of the same l)<)ne. 
 
 In licralltdri/ .sj/phllis the earliest bone-lesions are those in the 
 cranium and phalanges, occurring mostly in young in'ants. In 
 the cranium softening, caries, and su])puration are fre(iuent, with 
 circumferential jxTiosteal o\er-growth, forming the so-called Parrot's 
 nodes (1S79); or mere thinning of the skull from malnutrition and 
 pressure may occur, affecting especially the occipital bone. Caries 
 
 of the bony nasal septum and 
 
 l)alate bones also is seen. 
 Si/plilliilc daciiilitis is difficult 
 to distinguish from tuberculous 
 dactvlitis, but usuallv mav be 
 
 Fig. 460. — Sj-philitic perio.stcitis of left 
 tibia, early stage; duration three months. 
 Hereditary syphilis, patient also having 
 Hutchinson teeth and interstitial kera- 
 titis and marked genu valgum. Age thir- 
 teen years. (See also Figs. 461, 462, and 
 463.) Orthopaedic Hospital. 
 
 Fig. 461. — Same patient as Fig. 460: 
 Sabre-blade tibia (left), from photo- 
 graph two years after Fig. 460. Note 
 also syphilitic arthritis of right knee. 
 Orthopaedic Hospital. 
 
 recognized by the family history, existence of specific lesions else- 
 where, and results of anti-syphilitic remedies; it occurs in acquired 
 as well as in congenital syphilis (Figs. 458 and 459). In tuberculous 
 dactylitis microscopical examination or inoculation may reveal the 
 nature of the process. Constitutional anti-syphilitic treatment of 
 the mother, if the infant is nursing, always should be employed in 
 connection with local treatment. 
 
 From one to six years of age there are few manifestations of heredi- 
 tary syphilis, but after this period di.sease of the long bones is 
 frequent, especially of the tibise, one or both of which develop a 
 periosteitis, at first more or less well defined (Fig. 400), but later 
 
442 
 
 DISEASES OF BONE 
 
 diffuse and produeino; characteristic " sabre-})lade deformity" (Fig. 
 461). The bone may be softened early in tlie aft'ection, but later 
 thickening and elongation occur, and the bone is markedly sclerosed 
 (Figs. 402 and 4()3). If the pain does not yield to anti-syphilitic 
 remedies, the bone may be drilled in various places, thus relieving 
 tension; while during the stage of osteoporosis much comfort may 
 be derived from support by braces. The deformity is incural)le. 
 
 Fig. 462 
 
 Fig. 463 
 
 Figs. 4G2 and 46.3. — Skiugraphs of syphilitic periosteitis of tibiae, showing "sabre- 
 blade" deformity with hypertrophy and sclerosis of the bones. Age nine years. 
 Epi-scopal Ho.sipital. 
 
 Osteomyelitis rarely is due to syphilis, but in children gummatous 
 epiphyseal lesions may occur, and cause marked local over-growth 
 (Post, quoted by Nichols, 1907); or by softening and invasion of the 
 joint may produce tuberculous-like arthritis (p. 503). 
 
 In acquired syphilis the chief bony manifestation of the disease is 
 the periosteal gumma, which may begin with pseudo-inflammatory 
 symptoms, and occasionally breaks externally; under proper anti- 
 syphilitic treatment, however, it is apt to be absorbed, leaving a 
 depressed area on the surface of the bone (calvaria, nasal bones, 
 palate, sternum, tibia) due to dry caries and lacunar resorption, 
 
rVMORS OF liOXE 
 
 443 
 
 witli a tlii(k(Mi(>(l niar<;;in due to periosteal 
 prolitVratioii. It" the process is arrestetl l)e- 
 fore softening of tlie gumma occurs, perios- 
 teal nodes or exostoses may remain instead 
 of dei)ressi()n due to caries. Rarely" a dis- 
 tinct sequestrum forms; this is characteris- 
 tically worm-eaten in appearance and may 
 require many years for exfoliation. In all 
 cases where sinus formation occurs, sec- 
 ondary pyogenic infection is frequent, and 
 sequestrotomy, etc., may be necessary; in 
 other cases constitutional treatment alone 
 often is sufficient to relieve symptoms and 
 arrest the progress of the disease. Pain- 
 ful exostoses may be removed, or eburnated 
 bone (Fig. 464) drilled. 
 
 TUMORS OF BONE. 
 
 Fig. 464. — .Syphilitic osteitis 
 causing eburnation of the tarsal 
 bones. Patient had a chancre 
 eighteen years ago, and has 
 pulmonary emphysema which 
 may possibly be an etiological 
 factor in the bone disease. 
 
 Here may be recognized diseases which 
 comprise what Adami calls blastomatoid 
 
 conditions (p. 107), as well as true neoplasms of bone. In the 
 former category belong, perhaps, certain of the diseases described 
 
 as dystrophies of bone, as well as many 
 forms of exostosis, hyperostosis, etc. 
 
 Among the exostoses (p. 112) several 
 clinical types are recognizable, and deserve 
 short mention here. They are divided 
 into the cartilaginous and fibrous forms. 
 Cartilaginous exostoses are single or multiple 
 out-growths arising from epiphyseal cartil- 
 ages or in the neighborhood of epiphyseal 
 lines; they are most frequent at the upper 
 end of the tibia (Fig. 465) or lower end of 
 the femur (Fig. 466), and may cause trouble 
 by pressure on structures in the popliteal 
 space. Excision is the proper treatment, 
 removing also the portion of bone from 
 which they grow, as recurrence is frequent. 
 One typical aflFection, usually described by 
 the term Multiple Cartilaginous Exostoses 
 (Fig. 467), is thought by some to be a 
 distinct disease; but it seems probable that 
 it may follow any form of chronic inflam- 
 mation, infectious or toxic, whose lesions 
 are located in the bones, and it is certain 
 that it may be associated with, if not caused 
 by, rachitis or syphilis, may affect several 
 
 Fig. 465. — Cartilaginous 
 exostosis of outer tuberosity 
 of left tibia growing into pop- 
 liteal space. Begun at age of 
 sixteen years, and was re- 
 moved three years later. Re- 
 currence noted first five weeks 
 ago. 
 
444 
 
 DISEASES OF BONE 
 
 in the same family, 
 1903). It appears 
 seen one case in an 
 patient's attention 
 especially the long 
 epiphyseal lines (p 
 pressure. If this 
 
 and extend through se^•eral generations fLippert, 
 usually about. the age of pubert}', though I have 
 infant; and it may exist for some years before the 
 is attracted by the out-growths. These affect 
 bones of the extremities, occur mostly at or near 
 . 110), and seldom cause symptoms except rom 
 exists the offending exostoses mav be remo\ed. 
 
 Fig. 466. — Skiagraph of exostosis of femur spring- 
 ing from region of epiphysis and growing toward 
 diaphysis. Girl, aged sixteen years. Duration two 
 years. Began three months after injury from runner 
 of sled. Orthopaedic Hospital. 
 
 Fig. 467. — Multiple cartil- 
 aginous exostoses, in a negro 
 girl, aged thirteen years. 
 Children's Hospital. 
 
 Patients sometimes claim that a certain exostosis has appeared more 
 or less suddenly, or that another has decreased in size. Disturb- 
 ances of gr(n\-th, distortions, subluxations, etc., are frequent in the 
 long bones CBessel-Hagen, 1891). Fibrous exostoses arise either from 
 periosteum or its attached fascia or tendons. Several clinical types 
 are well known, including the ivory-like exostosis of the skull (men- 
 tioned at p. 112); subungual exostosis, found almost solely on the 
 great toe; exostoses of the facial bones, especially the nasal process of 
 the maxilla (leontiasis ossea may commence thus), and the mandible; 
 
TUMOh'S OF HOSE 
 
 445 
 
 and exostoses in connection with tendinou.s infirrti(>n.<i (see myositis 
 ossificans traumatica, j). 274), where a hursa may develop {exoatosia 
 hnrmta) in wliich cartihiginous l)odies may float. 
 
 FihrotiKis, arising From ixTiosteum, are rare; tliey form one \ariety 
 of ])()ly|)i in the naso])haryn\, and on the jaw constitute the "fibrous 
 epulis." 
 
 Choiidrotitas and O.stcoiiKi.s iuuc heen sufHciently described in 
 Chapter W. 
 
 Fig. 468. — Bone cyst of humerus, duration fifteen months; recent fracture from slight 
 injury. Cured by evacuation and scraping; and crushing in the thin wall of the cyst 
 to obliterate the cavity. Episcopal Hospital. 
 
 Bone Cysts. — These have been carefully studied by Bloodgood 
 (1910), who collected 89 cases; 09 of these had s(mie relation to osteitis 
 fibrosa (p. 437). The cyst usually is single, and contains thin, dark 
 brown fluid, never distinctly hemorrhagic, and never under great 
 tension; there usually is a distinct fibrous lining inside the bony 
 shell, and even when this is absent, evidences of fibrous osteitis can be 
 found microscopically. Unless the cysts are huge and of very long 
 duration, or there has been a pathological fracture (Fig. 408) there is no 
 alteration in the overlying periosteum. Small islets of cartilage may 
 
44G DISEASES OF BONE 
 
 exist in the cyst wall, and a few giant cells may be present; but neither 
 occurs in sufficient amount to render likely confusion with degener- 
 ated chondromas or with myelomas. The symptoms for which these 
 patients seek relief, as well as the proper treatment, have been given 
 in connection with fibrous osteitis (p. 437). The diagnosis from 
 other forms of cyst (degenerated chondromas, echinococcus disease, 
 etc.), which are rare, is not very important clinically, as the same 
 treatment is required. In hone abscess there usually is a history of 
 previous osteomyelitis, and the .r-ray shows the abscess surrounded 
 by sclerosed bone. From myeloma, except in cases of very short 
 duration, distinction usually may be made by .r-ray; myeloma 
 expands the bone rather abruptly, may cause periosteal prolifer- 
 ation, does not extend far up or down the medullary cavity, some- 
 times shows trabeculse, and has no fibrous lining beneath the cortex; 
 the benign bone cyst causes little expansion of bone, extends for 
 some distance up and down the medulla, and usually a faint, fibrous 
 lining can be detected. ^Myeloma occurs in young adults past twenty 
 years of age; and spontaneous fracture is rare. Bone cysts occur 
 mostly in children, and spontaneous fracture is frequent. Suh- 
 yeriosteal hematoma may resemble a bone cyst if encapsulated by 
 new-formed sub-periosteal bone. The cortex may be slightly eroded, 
 but the medulla never is involved. Such cysts are not uncommon 
 in the cranial bones of infants, from obstetrical injury, but may arise 
 elsewhere from contusion of bone. 
 
 Giant-celled Myeloma. — This tumor is described at p. 113; its 
 differential diagnosis from benign cyst has just been discussed. 
 
 Bone Aneurysms, so-called, usually are of the type of faUe osteoid 
 aneurysm mentioned at p. 113. Usually they are medullary sarcomas 
 of highly malignant type (spindle- or even round-celled), but they 
 may arise from a giant-celled myeloma. They are distinguished from 
 benign bone cysts by the frankly hemorrhagic nature of their con- 
 tents, which are under pressure; by much more rapid growth, early 
 perforation of the cortex and invasion of the soft tissues; and when 
 this stage has been reached, by expansile pulsation, sometimes accom- 
 panied by bruit. Giant-celled myeloma rarely presents any cystic 
 centre, and if one exists it is relatively small, and surrounded by 
 typical myelomatous tissue; whereas in the pulsating sarcomas of 
 bone, the blood-cyst comprises the main tumor, and the sarcoma cells 
 exist in a thinned-out layer around the periphery. 
 
 Treatment. — The treatment is prompt disarticulation above the 
 affected bone. Local recurrence or internal metastases usually occur 
 in a few months, and death follows within a year. 
 
 Sarcoma. — Bone is one of the most frequent sites of sarcoma, and 
 sarcoma is the most frequent tumor of bone. It is oftenest found 
 in the femur, tibia, and pehis. The tumor may grow from any con- 
 nective tissue cells in the bone, but not from myeloplaxes nor blood- 
 forming cells (p. 113). Bone sarcomas are classified clinically as 
 periosteal and medullary, and either form may be composed of round 
 
TUMORS OF HONE 447 
 
 cells or spiiidU' colls; round-celled sarconiiis of hone most t're(iuently 
 are derived from medullary tissues, where round cells (lymphocytes, 
 etc.) are found normally; while periosteal growths are most fre- 
 quently spindle-celled in tyi)e (see p. IKi). 
 
 Not every sarcoma growing in bone tends to form osseous tissue; 
 many of them remain unossified throughout, and some do not have 
 even calcareous deposits: (1) If the sarcoma arises from connective 
 tissue cells in bone (not osteoblastic in type) it is properly called 
 an Qstco-sarcoma (a sarcoma growing in hone); (2) such as are derived 
 from bone-forming cells (osteoblasts) alone deserve the name ossi- 
 fi/ing or osteoid sarcoma (malignant osteoma); whereas if a preexisting 
 benign tumor of bone (osteoma, chondroma, myeloma?) becomes 
 sarcomatous by anaplasia, it is termed an osteoma {chondroma, etc.) 
 sarcomatodes. In the first and last varieties no true bone is formed 
 by the tumor cells, such bone as is present being either the original 
 bone invaded by the tumor cells, or, according to Borst (1902), may 
 be newly formed bone due to stimulation of osteogenetic cells by the 
 adjacent tumor cells (such a 
 stimulation is denied by Adami). 
 The histological differentiation 
 of these types is difficult, and 
 a clinical distinction usually is 
 impossible; but as the prognosis 
 depends more upon the type 
 of cell from which the tumor 
 
 is derived than on the form of . J'^- 469.— Periosteal ossifying sarcoma of 
 
 ^, 11 'j^ • • J. J J 1 index metacarpal. Age forty-eight vears; 
 
 the cell, it is important to be duration six weeks. Amputation of fore- 
 
 informed that a pathological arm Death thirty months later, aft^r three 
 
 . . . ^ Y months illness from pulmonary metastases. 
 
 distinction exists between these Episcopal Hospital. 
 
 forms of bone sarcoma. The 
 
 most malignant growths are composed of the most highly undiffer- 
 entiated cells. Thus the more bone in a sarcoma, the less malignant 
 it is. 
 
 Symptoms. — The symptoms of sarcoma in general are given at 
 p. 117. Medullary or central sarcoma usually grows in the meta- 
 physes of the long bones, and for a time is prevented by the epi- 
 physeal cartilage from invading the joint. The patient generally 
 applies for pain before much deformity is present. Slight uniform 
 expansion of the bone end may be found, but the joint is not impli- 
 cated; in early stages joint motions are painless, and the tumor 
 pains most at night, not during exercise. These points serve to 
 distinguish it from arthritis. Pathological fracture is common, 
 and may be the first symptom. It is a question whether fracture 
 ever precedes and predisposes to sarcoma formation. A skiagraph 
 shows total destruction of the bone end, but a normal joint; yet 
 even the epiphysis disappears as the disease advances. Periosteal 
 sarcoma, usually osteoid in character, generally affects the diaphyses 
 of long bones, early causing a visible swelling, fusiform in outline. 
 
448 
 
 DISEASES OF BONE 
 
 but situated mostly on one side of the bone, not encircling it. It 
 is firm but not bony to the touch, thus being easily distinguished 
 from the medullary tumors which are bony hard until they thin the 
 cortex (stage of spina ventosa) or break through it. In a skiagraph 
 the periosteal tumor is seen to be caused by periosteal proliferation, 
 this membrane being raised from the shaft rather abruptly, and show- 
 ing newly formed bone in the wedge-shaped chink l)etween itself 
 and the cortex. The cortex is more or less eroded in the centre of the 
 tumor area, and in advanced cases the medulla is in^•aded. Radiating 
 spicules of newly formed osteoid tissue placed at right angles to the 
 shaft are present between the cortex and raised periosteum, in the 
 centre of the tumor. 
 
 Fig. 470. — Periosteal chondroma sarcomatodes. Age fiftj- years. Tumor for twenty- 
 five years, sudden growth for three months, following injury. (See Fig. 471.) Refused 
 any operation. Episcopal Hospital. 
 
 Diagnosis. — A rather rapidly growing (weeks and months) tumor 
 in bone, in a young adult, sometimes following trauma, and attended 
 by increasing pain, deformity, and disability, usually is a sarcoma. 
 Local heat, enlarged veins, tense shiny skin, etc., are present in 
 advanced cases. In case of doubt it is well to measure the limb's 
 circumference accurately at intervals of a few weeks; steady and 
 progressive increase in circumference denotes a malignant neoplasm. 
 Any benign tumor of bone, even if in existence for many years, which, 
 from trauma or no known cause, begins suddenly to grow rapidly, 
 should be considered malignant (Figs. 470 and 471). 
 
 Treatment. — ^The usual advice is to do amputation as early as 
 possible, the limb being removed at the nearest joint above the dis- 
 ease. But to one who considers the ultimate results, it is question- 
 
TUMORS OF BONE 
 
 449 
 
 able whotluT iuiythinj:; is ^niiiicd by this l)iit relief of i)iiiM. Internal 
 metastases must ofti'n he present when tiie patient first comes to 
 the siir^'eon, since they appear with such uniformitx' even after 
 removal of the limh; and local recurrence is so apt to follow excisions 
 or amputation in continuity, that there is no class of cases so dis- 
 
 FiG. 471. — Skiagraph of periosteal chondroma sarcomatodes. Same case as Fig. 470. 
 Tumor for twenty-five years, hard, adherent to bone. Three months ago the tumor 
 was broken from humerus by a fall. Since then there has been rapid growth, and much 
 pain. The tumor has grown fast again to the humerus. Episcopal Hospital. 
 
 heartening. ]Most patients die within two or three years from the first 
 appearance of symptoms of the disease. The object of any opera- 
 tion is to remove all of the tumor, and this usually but not always 
 implies disarticulation. This is always preferable to a long and 
 bloody excision or to any operation which will leave a useless limb. 
 If the patient regains some measure of health and comfort even for 
 29 
 
450 DISEASES OF BONE 
 
 a few months, before visceral metastases make tlieir presence known, 
 the operation cannot be said to have })een done in vain. Coley's 
 fluid (p. 117) should be employed as a routine, since at least it can do 
 no harm, and may be of value; the following figures give Coley's 
 own experience (1910) with its use in sarcoma of long bones: of 52 
 cases in which it was used, 10 (6 myeloid and 4 periosteal) patients 
 were well for over three years; of 3S cases in which it was not used, 
 5 (3 myeloid and 2 periosteal) patients passed the three-year limit 
 in good health. But as some of the myeloid sarcomas included 
 probably should have been classed as giant-celled myelomas, not as 
 sarcomas, the results are not as good as they seem. Opiates should 
 be administered freely in the latter stages. 
 
 Carcinoma. — Carcinoma of bone occurs as a metastatic growth, 
 being especially frequent in cases of prostatic and thyroid carcinoma, 
 but is also seen in carcinoma of the mammary gland, uterus, etc. 
 In the long bones the first symptom frequently is pathological frac- 
 ture, and this occurrence always should lead to search for primary 
 carcinoma, past or present. The fractures usually unite without diffi- 
 culty. In the spine, secondary carcinoma usually is a direct extension 
 from mammary or visceral carcinoma. Local treatment is useless. 
 The intolerable pain of vertebral in\'asion should be relieved by 
 opium given until effective; or the dorsal roots of the nerves may 
 be divided intraspinally. 
 
CHAPTER XV. 
 DISEASES OF JOINTS. 
 
 DYSTROPHIES OF JOINTS. 
 
 Tr was pointt'd out in the last chapter, in the section dealinii- with 
 Pi/.sfnipltir.s of Bone, that some of these conditions at times were 
 associated with changes in the organs of internal secretion. Thus, 
 Acromegaly is very constantly associated with changes in the hyi)ophy- 
 sis cerebri; Achondroplasia has been found associated with patho- 
 logical alterations in the thyroid; Osteogenesis Im])erfecta, with 
 changes in the adrenals; Osteomalacia, with changes in the ovaries, 
 while the administration of thymus or thyroid extract sometimes is 
 of benefit in cases of Osteitis Deformans. 
 
 As in the case of bone diseases, so in those w^hich affect the joints, 
 there is a class of chronic affections not definitely inflammatory, 
 though possibly due to remote or attenuated infection, to toxemias 
 or intoxications, or to changes in the organs of internal secretion. 
 Until more definite knowledge concerning them is gained, it is con- 
 venient to class them as dystrophies, since at least it is certain that 
 their more immediate cause is to be sought in disturbances of nutrition. 
 If it be asked why disorders due to disturbances of nutrition affect 
 the bones and joints rather than the soft parts, it may be replied 
 that the bones and joints have a less free and active circulation than 
 the soft parts, and like the hair, nails, teeth, etc., give early evidence 
 of circulatory disturbance; moreover, the soft parts themselves are 
 affected, but less conspicuously than the bones and joints. Slight 
 constantly recurring injuries, moreover, show their effects more on 
 the joints than the soft parts, and sometimes have a very marked 
 influence in localizing trophic lesions in one joint or set of joints 
 rather than in others. 
 
 The pathological changes in these dystrophic joints are those 
 of atrophy and hypertrophy; they may exist separately or together, 
 but in almost every case one change or the other predominates so 
 that the disease can be classed either as atrophic or hypertrophic 
 in type. It is possible that the atrophic type is a more acute mani- 
 festation of the same disease which in subacute or chronic form corre- 
 sponds to what is described as the hypertrophic type. The les ons 
 may affect the synovial membrane only, or, as is much more fre- 
 quently the case, the bones and cartilages as well; and in most cases 
 it is these structures which are first involved, the synovial membrane 
 being implicated secondarily. One joint or many may be affected, 
 the disease being classed as monarticular or polyarticular. 
 
452 DISEASES OF JOINTS 
 
 The noineiiclature of these diseases is much confused: two terms, 
 Rheumatoid Arthritis and Arthritis Deformans have been employed 
 indiscriminately by many wTiters, and have been applied to various 
 different diseases; so that if a surgeon today refers to a disease by 
 either of these terms, no one knows to what disease he refers unless 
 he further defines his meaning. Speaking generally, however, the 
 term rheumatoid arthritis usually has been applied by English-speaking 
 physicians to chronic joint diseases in which synovial lesions were 
 believed to predominate; and osteo-arthritis, or arthritis deformam, 
 a term introduced by the Germans, to those forms in which bony 
 changes are preeminent. The relation of these joint dystrophies 
 to affections of the organs of internal secretion is by no means so 
 evident as in some of the bone dystrophies, to which reference was 
 made above. But the favorable influence exerted by a long course of 
 treatment of thymus gland extract upon atrophic joint lesions is well 
 recognized, and the development of hypertrophic joint lesions, in 
 women, at a time when ovarian and thyroid changes are frequent, is 
 a fact to which Llewellyn Jones recently has called attention. 
 
 It is customary to speak of all these joint affections as different 
 forms of artliritis, though this term implies an inflammatory rather 
 than a degenerative condition. Yet these dystrophic joint diseases 
 have certain features which distinguish them from infections of joints, 
 and which it is \ery important to bear in mind. Our present knowl- 
 edge of the subject is due largely to the investigations of Goldthwait, 
 Xathan, and Llewellyn Jones (1909). The dystrophies begin insidi- 
 ously, are not attended by marked phenomena of inflammation nor 
 by constitutional reaction; they gradually progress, invading other 
 joints one by one; may exhibit slight remissions and exacerbations; 
 but the joints once aft'ected never entirely recover, and there is no 
 definite end to the disease. The infections have a definite and easily 
 remembered commencement ; are attended by the usual inflammatory 
 phenomena and constitutional reaction, even if slight in degree; 
 usually all the joints affected are attacked at or about the same time; 
 and when once the infection has run its course, the disease is gone, 
 and the joints recover, or retain permanent but never progressive 
 disability. 
 
 Atrophic Joint Lesions. — Here is placed a disease named "atrophic 
 artliritis" by Goldthwait (1905), and "metabolic osteoarthritis" 
 by Nathan (1906); it is the same as the "rheumatisme noueux" of 
 Trousseau (1868), the "chronic progressive articular rheumatism" 
 of Charcot (1 874), the "arthritis nodosa" of Waldmann (1884), the 
 "arthritis deformans" of Baumler (1897), and the "primary progres- 
 sive chronic joint rheumatism" of Pribram (1902). It is a poly- 
 articular, symmetrical affection, occurring in women oftener than 
 in men, and generally beginning in the fingers and hands, where it 
 may be localized by repeated slight trauma. It is seen oftenest in 
 young adults, but sometimes occurs in children. It affects first 
 the smaller joints of the hands and feet, especially the proximal 
 
ATh'Ol'UIC JOINT LESIONS 
 
 453 
 
 iiitcrpliiihiiiiical joints of the fin<jers; it profjresscs through muny 
 years, iii\a(liii<f the wrists, dhows, shoulders, ankles, knees, spine, 
 and maxillary joints. 'J'he hips seldom are aiVeeted. 
 
 The pathological ehan<:;e first noted is a localized suhclujndral atrophy 
 of the joint ends, fjiving them a "])unched out" appearance in a 
 skiai^ram (Fiij. 472); these are minute jjone cysts, due to osteoporosis 
 and lacunar resorption (Nathan,' 1!)(M)). Later the overlyin^f cartila<;e 
 degenerates, becomes invaded by comiective tissue from the un<ler- 
 lying s])ongiosa, and a so-called cartilaginous decubitus (pressure 
 
 Fig. 472. — Skiagraph of atrojjhic arthritis of liands. Girl, agf^d twenty-one years; 
 duration two yeans. Note bone cyst in distal end of proximal phalanx of middle finger 
 of left hand; absorption of heads of metacarpal bones in both hands; and atrophic 
 changes in bones of right carpus. Orthopaedic Hospital. 
 
 sore) is produced by pressure of the opposing bone. The cartilage 
 becomes completely absorbed, the joint cavity is lost, being filled 
 by loose and vascular connective tissue which shows no tendency to 
 contraction, and ankylosis (p. 467) rarely or never occurs. In skia- 
 graphs of advanced cases the joints appear to be ankylosed, because 
 the bones are in immediate contact or overlap, no clear cartilaginous 
 area intervening (Fig. 473). The joints become distorted, and sub- 
 luxated from muscular contraction; and in weight-bearing joints, as 
 
 1 Poncet considers such changes characteristic of one form of "tuberculous 
 rheumatism" (see p. 474). 
 
454 
 
 DISEASES OF JOINTS 
 
 the knee, tlie bone ends may become broadened and mashed out 
 rather flat, owhig to their atrophic state. No reactionary phenomena 
 are visible; no attempts at repair are made; no ecchondroses or osteo- 
 phytes are formed. 
 
 Fig. 473. — Skiagraph of atrophic arthritis of hands. Woman, aged thirty years; 
 (hiration five years. Changes more advanced than in Fig. 472. .Subluxations and 
 api)ar(>iit ankyloses. (See Fig. 474.) Orthopaedic Hospital. 
 
 Symptoms — The pathological changes shown in Fig. 472 may 
 ha\e existed for many months before subjective symptoms arrest the 
 ])atient's attention. Usually the first complaint is of stift'ness in 
 
 Fig. 474. — Atrophic arthritis. Duration six years. Same patient as in Fig. 47."i. 
 
 the fingers, worse in the morning and gradually passing away after 
 use; and the patient is dosed for "rheumatism." But on examina- 
 tion this is found not to be real stiffness, but rather weakness, passive 
 
ATROPHIC JOINT LESIONS 
 
 45: 
 
 motion being free and often i)ainless. Muscular atrophy is pro- 
 nounced, and often increased the swollen appearance of the joints 
 {V'l'j,. 474). Synovial cIVusion is rare, except from o\er-exertion or 
 trauma; it may he attended i)y considerable pain, but l)oth pain and 
 effusion subside when the joints are put at rest. Joint deformity 
 follows destruction of l)one ends and muscular contraction; but 
 thouiih motion may be limited or even ai)olished by periarticular 
 changes it is free within the range allowed. ^Motion is most limited 
 
 Fig. 475. — Skiagraph of atrophic arthritis of hands, advanced stage. Woman, aged 
 sixty-five years; duration forty-five years. Marked bone absorption, many subluxa- 
 tions. Two years later skiagraphs showed scarcely any bone left in shafts of meta- 
 carpals. (See Fig. 476.) Episcopal Hospital. 
 
 in the larger joints; in advanced cases the smaller joints may become 
 flail-like, and the skin covers the phalanges like a wrinkled glove 
 (Figs. 47.3 and 476). Lateral deviation, flexion, or hyperextension of 
 the phalanges may occur, and several dift'erent deformities may exist 
 in the same hand. The only constitutional symptoms are those of 
 slight cachexia and secondary anemia. 
 
 Prognosis. — The prognosis is gloomy. The disease steadily pro- 
 gresses, and in most cases the patient eventually becomes a helpless 
 cripple. 
 
456 DISEASES OF JOINTS 
 
 Treatment. — Good feeding and hygiene are reqnired; tlie only 
 favorable results I have seen have been in patients under the care 
 of Pemberton, whose plan of treatment is based on metabolic 
 studies, and is largely dietetic in nature (1913). Medicines are of 
 little value, but Nathan reports increasingly favorable results from 
 thymus extract, in doses of 10 to 20 grains three times daily. Guaiacol 
 carbonate sometimes is useful, in doses of from 5 to 15 grains three 
 times daily, continued for at least a year. This should be combined 
 with potassium iodide and tonics. Rest is necessary when exacerba- 
 tions occur from trauma or over-use; it often is best enforced by 
 use of orthopedic apparatus. Massage, hot baths, baking, etc., and 
 exercise short of fatigue, are of some value. After subsidence of acute 
 symptoms, deformity should be corrected by weight-extension and 
 tenotomy, or even by forcible manipulation, though this is more apt 
 to fracture the bones than overcome periarticular contractures. 
 
 Fig. 476. — Atrophic arthritis (advanced stage). Same patient as Fig. 475. 
 Episcopal Hospital. 
 
 Hypertrophic Joint Lesions.— These, as pointed out at p. 550, 
 are not rare as results of attenuated or remote infections; but there 
 are also certain forms of hypertrophic joint disease which seem to 
 be pure disorders of nutrition. In the polyarticular form, "Ileber- 
 den's nodes" (1804) are found; these consist essentially in hyper- 
 trophies of the bases of the distal digital phalanges, often accom- 
 panied by lateral deviation of the terminal phalanx (Fig. 477). The 
 thumb rarely is affected. The monarticular form is of more interest 
 to surgeons. It is the "arthritis deformans" of Volkmann (1882), 
 Schiiller (1900), and Hoffa (190G), the "chronic partial rheumatism" 
 of Charcot (1874), and the "hypertrophic arthritis" of Goldthwait 
 (1905). In this disease the influence of trauma frequently is con- 
 spicuous, hypertrophic lesions developing in a joint injured perhaps 
 many years before (Fig. 402), or in one which constantly is subject to 
 slight injury or strain. Static strain, from imperfectly reduced fracture, 
 or faulty attitudes, often is a cause. The disease affects men more 
 than women, usually those past forty years; and arteriosclerosis seems 
 to be a predisposing factor. Sometimes the affection is called senile 
 arthritis, and when the hip is attacked, it is known as "morbus coxae 
 
HYPERTh'OI'llIC JOINT LEGIONS 
 
 457 
 
 senilis." As ;i matter of fact, liowexcr, the knee is more often aifeeted 
 than the hi|), especially in women; in men the hi]) and spine arc 
 oftener attacked. in the spine the disease is called " sj)ondylitis 
 deformans" (j). (il(i). 
 
 Tlie earliest path()U)gieal cliange is said to oeenr in the joint car- 
 tihifje; this shows attemj)ts at proliferation, hnt the cartila<i;e eells 
 which border on the joint cavity are discharged into the synovial 
 finid, and the nnderlyini;- eartila«i;e is worn down by attrition of the 
 opposing hone, i)rodncing a "cupping" of the joint surface; while 
 
 Fig. 477. — Skiagraph of hands of patient, aged sixty-three years, with ijoljarticuhir 
 hypertrophic arthritis. Insidious onset, many years ago. Note hyjKTtroijhies f)f liases 
 of distal phalanges ("Heberden's nodes") and periosteal proliferations along shafts of 
 proximal and middle phalanges. Orthopaedic Hospital. 
 
 the more fortunate cartilage cells not subjected to such pressure 
 proliferate into the attachments of the capsule, and so produce spurs, 
 ecchondroses, and osteophytes, which cause a "lipping" at the joint 
 margins. The bone ends themselves often are the seat of porosis, 
 and in weight-bearing joints, especially the hip, very marked altera- 
 tions in the shape of the bone ends may occur; thus the head of the 
 femur may be worn away, the acetabulum enlarged upward and 
 backward ("wandering acetabulum"), while the base of the femoral 
 neck and the acetabular borders become studded with osteophytes. 
 
458 
 
 DISEASES OF JOINTS 
 
 The angle between the neck and shaft of the femur is decreased, and 
 coxa vara results. The earliest skiagraphic evidences of these bone 
 changes are observed in shari)er angularity of the bone margins. 
 The edges of the tibial condyles become sharj), the patella becomes 
 square, the astragalus and scaphoid lose their gentle curves, and 
 eventually distinct exostoses are observed (Figs. 478 and 479). These 
 occur especially at points of strain, where ligaments or tendons are 
 attached ; they are not always confined to the immediate neighborhood 
 of joints. The joint ligaments may be gradually destroyed by the 
 
 Fig. 47S. — Skiagraph of monarticular hypertrophic arthritis of knee. Woman, aged 
 forty-nine years. Duration two years. Insidious onset; no injury. (See Fig. 479.) 
 Orthopa?dic Hospital. 
 
 degenerative process, and, according to Marsh, the joint may become 
 weakened, loose, even flail-like; this occurs oftenest in the knee. 
 Usually, however, for a time at least, limitation of motion is observed 
 owing to periarticular fibrous changes or the interlocking of osteo- 
 phytes, but ankylosis rarely or never occurs. If the obstructing 
 osteophytes are removed, free motion may be restored for a time. 
 In the shoulder-joint the long tendon of the biceps may fuse with 
 the underlying bone. 
 
 Symptoms. — The patient complains of weakness and stiffness in 
 the affected joint. It creaks on motion, and motion commonly is 
 
IJYl'PJin'h'ol'lllC JOIST LESIONS 
 
 459 
 
 limited. Srvere referrorl pain as woll as local pain may hv IVlt. The 
 uciicral health is not materially imi)aire(l. If the small joints are 
 alVeeted the\ present Hehenlen's nodes, hnt rarely {jjive snhjective 
 symptoms. Tlie disease tyi)ieally is monarticular in the beginning, 
 and often remains so; but other joints may be involved in time. The 
 (ll(i(lii(i.s-is depends on excluding an infectious origin, whicli often is 
 dilhcult, and sometimes impossible; on observing the localization 
 of the process to one of the larger joints which has ])een injured or 
 is the seat of constant strain or reix'ated slight trauma; and on the 
 
 Fig. 479. 
 
 -Hj-pcrtrophic arthritis of knee, lateral view. Same patient as Fig. 478. 
 Orthopjedic Hospital. 
 
 results of skiagraphic examination. Atrophic arthritis is polyar- 
 ticular, aflfects first the smaller peripheral joints, and spreads cen- 
 tripetally, and occurs in women in early adult life. Hypertrophic 
 arthritis is monarticular, affects a large joint, and occurs in persons 
 past middle life. Both have an insidious onset, are chronic from the 
 start, run a long and tedious course, and neither is accompanied by 
 inflammatory or constitutional symptoms. 
 
 Treatment. — Sometimes it may be possible to prevent the devel- 
 opment of hypertrophic lesions by relieving a joint from strain, 
 
460 
 
 DISEASES OF JOINTS 
 
 protecting it from injury, or by active treatment of an underlying con- 
 dition, such as internal derangement of the knee-joint (p. 412). In the 
 cure of the disease, a painful joint should be put at rest. Confinement 
 to bed seldom is necessary, the use of plaster of Paris splints, braces, 
 etc., usually being sufficient. Imm()l)ilization should not be a})Solute, 
 however, nor should it be continued too long, since this promotes 
 stiffness. Such exercises as can be taken without too great fatigue 
 
 should be encouraged. Occasionally 
 one or more bony spurs which 
 markedly limit motion, or cause 
 pressure symptoms, may be re- 
 moved by saw or chisel. Arthro- 
 desis (p. 528) has been employed 
 in some cases, especially at the 
 hip (Figs. 480 and 481)' and the 
 knee, to relieve pain by permanent 
 
 Fig. 480. — Albee's method of arthro- 
 desis of the hip (See Fig. 481.) 
 
 Fig. 481. — Albee's method of arthro- 
 desis of the hip. 
 
 Fig. 482. — Charcot joint. Age fifty-one 
 years. Duration, three months; followed 
 sprain while climbing. Lost knee-jerks and 
 Argyll-Robertson pupils. Orthopaedic Hos- 
 pital. 
 
 joint-fixation. General hygienic treatment is of value, but no drug 
 has much influence on the disease. 
 
 Neuropathic Joints (Charcot, 1868). — In tabes dorsalis the joints 
 are subjected to unusual strain, as deep sensation is lost, and the 
 patient is not aware of the injury he inflicts upon them in walking, 
 pulling himself up stairs, etc.; the nutrition of the bones also is dis- 
 turbed, predisposing them to distortion and fracture. So-called 
 spontaneous fracture is not rare, and sometimes occurs some time 
 
INFECTIONS OF JOINTS 461 
 
 hc'l'ori' (Iclinitc talx'tic syiuptoms doxolop. As a rule only one joint is 
 afVec'trd hy the dystrophy, most often the knee; hut the shoulder, 
 elhow, aid<l('. and hi]) soinetinies are att'eeted. Painless effusion may 
 he the first synii)toin, and this may exist so lon^ as to induce relaxation 
 of the lii:;ainents, or even a flail-joint, hefore the patient realizes its 
 condition (Fi^- 1''^-). The hone ends heeome distorted from pressure, 
 and pieces may he hroken oft' and lie free in the joint. Osteophytes 
 fre((nentl.\' \:^to\\' in the fihrous tissues surroun(Hnj!; the joint. 
 
 Diagnosis. — The diagnosis de{)en(ls on the detection of constitu- 
 tional symptoms of tahes, associated with a nearly painless dystrophy 
 of one of the larger joints, with ettusion and ahnormal mohility. 
 In synngoimjcUa similar changes may occur, usually in the upper 
 extremity. 
 
 Treatment. — This consists in care of the general tahetic conditi(jn, 
 and support to the diseased joint; massage may improve the con- 
 dition of the surrounding muscles. In some cases arthrodesis may he 
 done, in the endeavor to restore stahility. Very rarely amputation 
 may he required. 
 
 LOOSE BODIES IN JOINTS. 
 
 This condition has many of the same symptoms as interned drranqc- 
 mcnt of the knee-joint, referred to at' p. 412, but the patliogenesis 
 is dift'erent. The knee is affected in the vast majority of cases. The 
 loose bodies, or "joint mice" as they are called, may be entirely free, 
 or may remain atfacKecTto the capsule by a pedicle. They may be 
 deri\ed from hypertrophied synovial fringes, from organized blood- 
 clot, flakes of fibrin, etc.; from detached chips of bone or cartilage; 
 or from ecchondroses, osteophytes, etc., developed in hypertrophic 
 arthritis. One or an innumerable number of such bodies may be 
 present. 
 
 Symptoms. — The symptoms are those of the underlying disease 
 (villous, or hypertrophic arthritis), or of old injury, wdth occasional 
 locking of the joint from impaction of the loose body. This often 
 is followed by an attack of acute synovitis. If the loose bodies are 
 large, or present in sufficient numbers, they may be detected by 
 palpation, and sometimes they are dense enough to be detected in a 
 skiagraph. . Care should be taken not to mistake a normal sesamoid 
 bone or other extra-articular structure for a loose body. 
 
 Treatment. — Usually nothing short of arthrotomy and remo\al 
 of the bodies will give relief, unless the joint is kept immobilized; 
 and even after such an operation the joint lesion which caused the 
 formation of the loose bodies will recpiire its appropriate treatment. 
 
 INFECTIONS OF JOINTS. 
 
 Pathology. — Infection may reach a joint through external wound, 
 directly through the blood-stream, or from a neighboring focus of 
 
462 
 
 DISEASES OF JOINTS 
 
 inflammation, usually in bone. Wounds of joints have been considered 
 in Chapter XIII. ]\Iost joint infections secondary to bone lesions 
 are tuberculous in origin; these are discussed at (p. 476). In this 
 place it is desired merely to enumerate briefly the main pathological 
 changes which occur in joints as the result of infection. 
 
 Synovitis is the earliest stage; the synovial membrane is congested 
 and swollen, and minute ecchymotic areas may be present in it; 
 effusion into the joint cavity occurs, due both to increase in the 
 natural synovial secretion and to the formation of inflammatory 
 lymph. Fluid collects in the joint because it is a free surface, and 
 wherever a free surface exists effusion predominates over edema. 
 In mild infections, and in aseptic inflammations such as sprains, 
 contusions, etc., the eflfused fluid usually remains serous in type; but 
 infections due to pyogenic cocci usually, and those caused by the pneu- 
 mococcus, gonococcus, etc., often end in suppuration, constituting 
 the condition of liyarthrosis or empyema articidi (Fig. 483). Arthritis 
 is a clinical term used, in contradistinction to synovitis, to imply 
 predominant involvement of structures of the joint other than the 
 synovial layer of the capsule; and osteo-arthritis signifies involvement 
 
 Fig. 483. — Pyarthrosis of wrist. Residual abscess three months after complete 
 healing of infected hand and forearm. Orthopsedic Hospital. 
 
 of the bone ends. In some cases of subacute infection no marked 
 effusion occurs, but proliferation of the synovial villi is the main 
 feature, producing villous arthritis; this is believed by some to be 
 caused by a specific diplococcus, discovered in 1900 by Schiiller. 
 
 If recovery ensues while the eft'usion is still serous, little subse- 
 quent trouble may be experienced; often, however, the fluid is not 
 entirely absorbed, and chronic serous synovitis {hydrops articidi, p. 464) 
 develops. When the exudate has been sero-fibrinous some organiza- 
 tion of the inflammatory material usually occurs, and the joint ca\ity 
 is more or less obliterated by bands of adhesions, which may restrict 
 motion. When suppuration has occurred, more or less destruction 
 of the cartilages, ligaments, etc., is inevitable; complete disorganiza- 
 tion of the joint may occur; and as gradual repair by organization 
 and cicatrization sets in, the bones become welded together, more or 
 less firmly, and frequently in bad position, in a condition of ankylosis 
 (p. 467). Ankylosis may be entirely bony, or due to fibrous adhesions 
 allowing a very limited range of motion; limitation of motion due to 
 periarticular changes (contraction of capsule, ligaments, tendons; 
 locking of osteophytes, etc.) is not spoken of as ankylosis, which term 
 
SYXOVITIS AND Aia'llUlTlS M).\ 
 
 al\va\s implies loss of motion from intra-artlculur adhesions, iihrcnis or 
 osseous in character. Owing to the distention of the capsule during 
 the stage of effusion, and to changes in the hone ends, patholofiiral 
 dislocation of the joint may occur, from muscular action, or the 
 force of gravity. 
 
 S3rmptoms. — Joint effusion is shown by increase in circumference, 
 with bulging of the capsule at its weakest parts. In the knee the 
 j)atella is floated up from the condyles, and when the cjuadriceps 
 extensor is relaxed, the i)atella can be made to taj) against the bone; 
 the capsule bulges on each side of the quadriceps tendon, and the quad- 
 riceps bursa is distended (Fig. 484). When much fluid is present 
 fluctuation can be elicited. In the elbow the capsule l)ulges on both 
 sifles of the triceps tendon; in the ankle, beneath the tendo Achillis 
 and anteriorly. In the wrist swelling is more marked on the dorsum; 
 while in the hip and shoulder effusion is more difficult to appreciate. 
 Any joint which is the seat of effusion tends to assume a position 
 in which the capsule is most relaxed; this usually is in moderate 
 flexion, and in the hip slight abduction as well as flexion is charac- 
 teristic. Great pain is felt in the affected joint, and from pressure 
 of the effusion on neighboring nerves referred pain may exist. ^lus- 
 cular spasm is present, and may cause starting or jumping pains 
 in the joint, from time to time, especially during sleep. Joint motion 
 is painful, and the joint itself is tender. As a rule, the bone ends are 
 not tender in simple synovitis nor in arthritis not secondary to osseous 
 disease; but crowding the bones together causes pain. The affected 
 joint may be hot even in simple synovitis, but unless suppuration is 
 present there is not much constitutional disturbance, nor is the 
 affected joint red. Suppuration may be ushered in by a chill, or there 
 may be no change except in the temperature. In pyarthrosis of the 
 larger joints the patient becomes gravely ill, and all the constitutional 
 signs of septicemia or pyemia develop. The joint becomes more tense 
 and painful, exquisite tenderness develops, dusky redness with edema 
 of the skin may be present, and unless the pus is evacuated it may 
 perforate the capsule and invade the soft parts. Spontaneous dis- 
 location is most frequent in the hip. 
 
 If villous arthritis develops, the joint does not present fluctuation, 
 but is doughy, and the capsule does not bulge but presents a more 
 uniform enlargement, and it is evident that this is due partly to peri- 
 articular thickening. The condition becomes subacute or chronic, 
 and is then characterized b}' creaking and crackling on motion, slight 
 permanent loss of full extension, and moderate disability. 
 
 Treatment. — The treatment of acute synovitis consists in local 
 rest of the joint, secured by proper splinting, and in the case of the 
 lower extremity by rest in bed, usually with weight extension. If 
 this treatment is instituted promptly, apparent recovery may ensue 
 in a few days; but the joint, especially the knee, should be protected 
 for several weeks by a light plaster case, as recurrence of effusion, 
 and development of hydrops is much to be feared. ^lassage of the 
 
464 DISEASES OF JOINTS 
 
 surrounding muscles, not of the joint itself, is of value for restoration 
 of function after all inflammatory symptoms have been absent for 
 several weeks. When the patient comes under observation at a 
 later stage, with the joint in bad position, or suppuration threatening, 
 weight extension should be applied as well as splinting; the latter 
 alone sometimes is sufficient for the upper extremity. The joints 
 should be kept in the position which will be least useless should 
 ankylosis occur: the shoulder in slight abduction; the elbow and 
 ankle at a right angle; the wrist and knee in full extension; and the 
 hip in full extension and slight abduction, but without either external 
 or internal rotation. The forearm should be kept nearly in full 
 supination. 
 
 Suppuration is treated by aspiration (which may be used as a 
 diagnostic measure) and injection of 2 per cent, formalin-glycerin 
 solution, the joint meantime being kept at rest, and such constitu- 
 tional measures being used as the patient's condition demands. 
 Aspiration and formalin injection may be repeated a number of times, 
 though the injection may be very painful; and usually the infection 
 may be controlled in this way, the fluid gradually becoming serous, 
 and the joint inflammation subsiding with preservation of a fair 
 degree of motion. Should, however, improvement not be secured 
 after two or three aspirations, the joint should be incised, and treated 
 as detailed for septic arthritis following trauma (p. 387). 
 
 Villous artliritis, when acute, is treated as synovitis, by rest, and 
 antiphlogistic or sorbefacient applications. In its more usual sub- 
 acute or chronic stage, benefit is derived from massage, passive 
 motion, baking, hot and cold douches, passive congestion, etc. Any 
 source of infection (see p. 47(3) should be removed, and the patient's 
 general health improved. Painful joints should be supported by 
 suitable apparatus. 
 
 Acute Arthritis of Infants (T. Smith, 1874) almost invariably sup- 
 purative, occurs as a hematogenous infection, and probably always 
 is secondary to acute epiphysitis (p. 43(3). The diagnosis is not 
 always easy, unless the condition is constantly in mind; when the 
 pus has perforated the capsule, making beneath the muscles a tense, 
 hot, painful swelling, with enlarged veins, a diagnosis of sarcoma has 
 often been made. I saw such an error in an infant with arthritis of 
 the shoulder, when I was house-surgeon at the Episcopal Hospital. 
 The disease seldom results in ankylosis, but leaves a deformed, 
 flail-like joint. 
 
 Chronic Serous Synovitis, or Hydrops Articuli, occurs oftenest 
 in the knee, usually the result originally of slight trauma causing 
 acute synovitis with efl'usion, which has never entirely subsided, 
 owing to inefficient treatment, for which the patient is more often 
 to be blamed than the surgeon. The condition is maintained either 
 by recurring slight trauma, or by some remote or attenuated infec- 
 tion. Sometimes hydrops seems to be chronic from the start; in 
 such cases careful search should be made for anv site of infection 
 
nV DROPS AHTICULI 
 
 41 ;r) 
 
 which may maintain a toxemia and tiius interfere witii joint metab- 
 olism. 
 
 The joint is distended, but rarely tense; floatinj^ of the patella 
 and fluctuation are detected easily; and no signs of acute inflammation 
 or constitutional disturbance are present (Fig. 4S4). If pain is entirely 
 absent, the existence of a Charcot joint should be suspected (p. 4G0). 
 The patient complains of weakness and insecurity in the knee, of its 
 tiring easily, of a feeling of fulness and discomfort on partial flexion, 
 and of inability to flex the joint completely. He stands usually with 
 the knee not quite fully extended, 
 though passive extension may produce 
 no discomfort. There may be a mod- 
 erate degree of villous hypertrophy, and 
 "joint mice" may develop; indeed such 
 conditions themselves may maintain a 
 state of chronic synovitis by the con- 
 stant irritation they produce. Increase 
 in the pads of subpatellar fat is not 
 unusual (see Lipoma Arhorescens, p. 
 503); and the neighboring bursse may 
 be clironically inflamed. 
 
 Treatment. — Any source of infection 
 which can be detected should be cured, 
 and intestinal putrefaction and toxemia 
 should be overcome if present. Localh', 
 treatment should be instituted as for 
 acute synovitis, by putting the joint 
 at absolute rest for several weeks. 
 This, wqth moderate uniform pressure 
 by plaster of Paris or adhesive strap- 
 ping, may cause the effusion to dis- 
 appear. Counter-irritation may assist 
 absorption. It may now be possible 
 to detect a loose cartilage or other 
 form of "joint mouse" wdiich is partly 
 responsible for continuance of the condi- 
 tion. Rarely aspiration of the fluid may 
 be employed for the same purpose, and 
 
 to hasten absorption; it should be followed by injection of 2 per cent, 
 formalin glycerin solution. I once did arthrotomy, finding the under 
 surface of the patella and opposing femoral cartilage roughened, and 
 placed a drainage tube across beneath the patella; the patient recovered 
 perfect function in a few weeks, and in the eight years he was under 
 observation there was no return of the condition, which had resisted 
 conservative treatment for months. Such a plan rarely is proper, 
 because the disabilit}^ never is total, and the disease entails no risk 
 to life. If rest and immobilization fail to secure absorption of the 
 fluid, or if, as is usual, eft'usion recurs when joint function is resumed, 
 30 
 
 Fig. 484. — Hydrops articuli of 
 left knee, slight of right. Gonor- 
 rheal arthritis of left knee twelve 
 years ago. Knee always swollen 
 since. Orthopaedic Hospital. 
 
466 DISEASES OF JOINTS 
 
 the patient may be allowed to walk about in a gypsum case or brace; 
 and hot and cold douches, vigorous massage of the joint and leg and 
 thigh muscles during many months, and elastic compression may 
 bring a certain measure of relief. When joint mice are present, they 
 may be removed by arthrotomy, in the hope that they are the cause 
 of the recurring effusion. It is rare for a permanent cure to be 
 obtained. 
 
 Intermittent Hydrarthrosis is a very obscure affection of joints, 
 generally believed to be of vaso-motor origin. The effusion occurs 
 suddenly, within a few hours, and subsides as rapidly, or within a 
 day or two ; the attacks occur at more or less regular intervals, perhaps 
 daily for a certain portion of each year, or every few months. Almost 
 any joint may be afl'ected, and men as well as women are subject 
 to the disease. Treatment is purely symptomatic. 
 
 Periarthritis. — Periarthritis is a vague term under which it is 
 convenient to group various subacute or chronic periarticular con- 
 ditions until their true pathology can be determined. These lesions 
 seem to be more frequently a cause for complaint around the shoulder 
 than elsewhere, though they occur sometimes in other joints. They 
 usually are caused primarily by trauma (sprains, subluxations, etc.), 
 and are maintained either by static strain (especially in the sacro- 
 iliac joint), or frequently recurring trauma. The condition w^as 
 mentioned at p. -08 and 385. Codman (190G) has drawn attention 
 to the subdeltoid bursa as the main factor in such disability; while 
 T. T. Thomas (1911) thinks cicatricial contraction of the axillary 
 portion of the capsule, resulting from sprain or self-reduced sub- 
 luxation, is a more frequent, if not the only cause of the condition at 
 the shoulder. The neighboring nerves (axillary plexus, sacral plexus 
 and sciatic nerve) may be involved in periarticular adhesions, and 
 thus complicate the case. 
 
 Symptoms. — The symptoms are pain and disability, and in the 
 shoulder especially limitation of abduction and external rotation. 
 Tendinous or bursal crackling often is present. "Sprain fracture" 
 of the greater tuberosity of the humerus sometimes exists. Each 
 case requires careful individual study to determine the original 
 cause, and if possible the pathological lesion present. Suhdeltoid 
 bursitis is characterized by tenderness below and in front of the 
 acromion when the arm hangs by the side, this tenderness disappearing 
 when the arm is abducted and the bursa disappears beneath the 
 acromion; in chronic cases w'ith adhesions abduction is impossible, 
 and the diagnosis is more difficult, but usually there are no physical 
 signs in the axilla. Implication of nerves is recognized by symptoms 
 of neuritis, and sometimes trophic changes in the fingers. ^Nly own 
 experience leads me to coincide with Thomas's views, that in most 
 cases the main lesions are in the axillary region of the joint, and not 
 hi the subdeltoid bursa, 
 
 Treatment. — Massage, pass'.ve motion, baking, hot air douche, 
 etc.; ma\' all be tried. Improvement is slow, In resistant cases the 
 
ANKYLUSJS 
 
 4«7 
 
 patient should l)c ctlicri/cd, the adlicsioiis t'orcihly ruptured, and 
 the arm dressed in aixhiction. hnproxcnient in the nutrition of the 
 hand may t'oUow sueii treatment. If it he certain that tlie snl)- 
 (K'hoid l)nrsa is the seat of adhesions wiiieh eamiot \)v ruptured hy 
 manijiuhition, tlie hursa may he opened and the adhesions cut or the 
 hursa exeisech Dissection may reUeve an intractahh- neuritis, especially 
 of the sciatic ne^^■e. 
 
 Ankylosis. This is a fixation of joints hy intra-articular adhesions. 
 Aeet)rdinii- to the character of these adhesions ankylosis is classed 
 ■d» fibrous or Ixnn/. It is worth while to repeat here again that limita- 
 tion of motion from extra-articnlar causes is not ankylosis; it has 
 been called "false ankylosis." Thus in the dystr()])hies of joints 
 discussed in the opening i)aragraphs of this chai)ter, there is limitation 
 of motion, hut not ankylosis. True anky- 
 losis, whether fibrous or bony, probably 
 always is the result of infectious arthritis 
 or of trauma. Complete bony ankylosis 
 rarely occurs except from trauma, most 
 cases of bony ankylosis due to arthritis 
 presenting only a few bands or processes 
 of bone uniting the articulating surfaces, 
 the remainder of the joint cavity being 
 filled up by fibrous adhesions. If only 
 fibrous ankylosis is present it usually is 
 possible to detect a few degrees of motion 
 if the joint is carefully examined under an 
 anesthetic. 
 
 Treatment. — The treatment of ankylosis 
 in tuberculous artliritis is considered at 
 p. 487. What is said here applies to 
 ankylosis due to other forms of infection 
 (pyogenic, pneumococcic, typhoid, etc.), 
 or to trauma. If ankylosis occurs with the 
 limb in good position, no treatment may 
 be advisable, especially in the aged, those 
 with visceral disease, etc. A stiff hip is 
 largely compensated for by mobility in the 
 lumbar spine; a stiff elbow, if the hand can 
 be brought to the mouth, may be useful enough; and movements of the 
 scapula on the trunk largely compensate for ankylosis in the scapulo- 
 humeral joint; but almost any joint which is in bad position will be 
 improved by treatment. With very few exceptions, however, no opera- 
 tion should be undertaken until all signs of active disease have long 
 since subsided. In cases of fibrous ankylosis, where the disease is still 
 subsiding, the use of weight extension or of elastic compression 
 against a splint, or of a splint with Stromeyer screw (Fig. 485), may 
 secure improved position; and in cases of fibrous ankylosis and false 
 ankylosis in which definitive healing has occurred, the surgeon may 
 
 Fig. 485. — Brace for kuee 
 with Stromeyer screw, to pro- 
 duce gradual extension. Ortho- 
 ptedic Hospital. 
 
468 
 
 DISEASES OF JOINTS 
 
 make attempts to secure improved position by rupture of adhesions 
 under an anesthetic {arthrolysis or brisement force), always making 
 movements of flexion before those of extension (to avoid damage to 
 the important periarticular structures in the flexures of joints), and 
 seeking to rupture adhesions by abrupt movements of small excursion 
 rather than by prolonged or violent pressure. The joint should then 
 be immobilized in improved position until inflammation subsides, when 
 gentle passive movements should be begun and active use encouraged. 
 While such measures often secure improved position and sometimes 
 a moderate range of motion in cases of false or flbrous ankylosis, 
 in bony ankylosis open operation is required. 
 
 Fig. 486. — Instruments used in excision of joints: (1) Blunt-pointed resection knife. 
 (2) Periosteal elevator. (3) Guide for Gigli wire saw (4), and (5) handles. (6) Chain 
 saw. (7) Butcher's saw, the blade of which can be reversed, so as to cut upward. 
 
 If it is not desired to restore motion to the joint, simple osteotomy 
 may suflflce to secure good position. This is seldom employed except 
 at the hip. Here the neck of the bone may be divided (Adams, 1871), 
 but as this often is distorted by disease, subtrochanteric osteotomy 
 of the femur (Gant, 1872), is preferable (p. 487). Excision of joints 
 
EXCISION OF JOINTS 
 
 m) 
 
 for ankylosis is employed to eorrect (leforinit\' where osteotomy will 
 not snffice, as at the knee, shoulder, and elbow. In the latter situa- 
 tions a movable joint is soUf,dit, hut at the knee the object of excision 
 is to secure ankylosis in full extension, the most useful position. 
 Excision of the knee is done without an Esmarch hand by a transverse 
 incision. sli»j:htly convex downward, across the front of the joint from 
 the j)osterior eds>;e of the base of one condyle to that of the other; the 
 skin is dissected up until the upper border of the patella is exposed 
 and the quadriceps tendon is 
 divided at its insertion into 
 the patella; the knee-joint is 
 acutely flexed, and the intra- 
 articular ligaments are divided. 
 The condyles of the femur 
 being thus cleared, the saw 
 is applied to them and a sec- 
 tion about half an inch thick 
 is remov'ed, not at right angles 
 to the long axis of the femur, 
 but obliquely from without 
 inward, from before backward, 
 and from above downward; 
 in other words, in such a 
 manner that the posterior 
 internal portion of the sawn 
 surface shall be the longest, 
 and the anterior external the 
 shortest. The tibial condyles 
 are then sawed across at right 
 angles to the long axis of the 
 leg, but somewhat bevelled 
 antero-posteriorly so as to 
 correspond to the section of 
 the femur. The tibial con- 
 dyles with the attached pa- 
 tella are then removed in one 
 mass {Ashhurst's operation, 
 1884). Barely enough of the 
 femur and tibia are removed 
 to allow the limb to come 
 
 straight; the posterior ligaments always, and the lateral ligaments 
 whenever possible, are left intact. The periarticular tissues are 
 sutured with clironic catgut, and the skin is closed with provision 
 for drainage for twenty-four hours. The limb is dressed in plaster 
 of Paris and immobilization continued for six or ten weeks until 
 union is firm. If complete bony ankylosis (in bad position) is present 
 already, it is sufficient to excise a wedge of bone to restore the axis 
 of the limb (Figs. 487 and 488). In all cases of excision of the knee, 
 
 Fig. 487. — Ankylosis of knee in flexion, in a 
 girl of twelve years; result of arthrectomy for 
 tuberculosis nine years previously. (See Fig. 
 4S7.) Episcopal Hospital. 
 
470 
 
 DISEASES OF JOINTS 
 
 the liml) should he sui)iJ()rte(l hy a hraee for a year afterwards. The 
 elhoic is excised through a straight posterior iueision spHtting the 
 triceps muscle near the inner border of the olecranon, and carefidly 
 separating its tendinous expansion from the olecranon. Injury of the 
 ulnar nerve should he avoided; it is most liable to injury just below 
 the level of the joint close to the inner border of the olecranon. After 
 the lateral ligaments have been divided the joint may be luxated. 
 Enough bone is removed (leaving the radial insertion of the biceps) 
 
 to ensure a false joint being 
 established; a space of at least 
 one inch and a half should ex- 
 ist between the humerus and 
 bones of the forearm, to ensure 
 free motion. The limb is im- 
 mobilized only until the soft 
 parts heal; active use is then 
 encouraged. Return of func- 
 tion depends largely on pre- 
 servation of the periosteum 
 into which the triceps inserts, 
 and its fibrous expansion over 
 the radius. The shoulder is 
 excised through an anterior 
 incision in the hollow between 
 the coracoid and acromion pro- 
 cesses, thus avoiding injury to 
 the branches of the circumflex 
 nerve. The long tendon of 
 the biceps is pushed to one 
 side. The capsule is opened 
 as in shoulder-joint amputa- 
 tions, and the muscles inserted 
 into the tuberosities are 
 divided as there described. 
 Usually the section of the 
 humerus is made through the 
 surgical neck; but it is better 
 to remove more bone from the 
 glenoid than from the humerus, 
 since restoration of function 
 depends largely on the preservation of the muscular insertions in the 
 latter. After-treatment is the same as in excision of the elbow. In 
 all these excisions, it is well, if possible, to open up the line of the old 
 articulation first, by breaking adhesions and sawing across bridges of 
 bone, and then to remo^•e from the bone ends so much as is necessary. 
 Attempts to excise a joint in one block, except by experienced sur- 
 geons, result in the removal of too much or too little bone. Excision 
 of the icrist seldom is required; in most cases an erasion (p. 4<S(3) suffices. 
 
 Fig. 4bS. — Hesulr of cuneiform resection of 
 the knee shown in Fig. 486. The epiphyseal 
 lines have been carefully preserved. Epis- 
 copal Hospital. 
 
SPECIAL ISFECTIOSS OF Till': JOISTS 171 
 
 11' t'oniial cxcisidii is doiic, the Ix'st incision is that oi Alyiitcr (l.S!)lj, 
 splittini;- the ddrsmii of the hand hctwccn the index and middle 
 finfi;('rs. Ankylosis is the desired resnlt. 
 
 Arfliropldsti/ is an operation desi^nied to secure a niovai)le joint 
 with the niinininin anioinit of hone resection, by interposition between 
 the bone ends of pedieled flaps of fat, fascia, or muscle. This operation 
 has been ])ractised with success by Murphy (1904), Ilu^uier (100.")), 
 G. (i. Davis (H)()S), and others. It permits the formation of a j^ood 
 movable joint at the knee if the lateral and patellar iif^aments are 
 preserved and the bone ends so shaped as to prevent luxation; 
 and in the elbow and shoulder it preserves the free motion sectired 
 l)y the ordinary reseetion, at the same time rendering the joint more 
 stable, because less bone has to be removed. But the operation 
 is difficult, requires special training and experience in joint surgery, 
 and is not always successful. Baer (1909) uses pig's bladder instead 
 of autoplastic flaps. Lexer (1908) has successfully transplanted, 
 from ami)iitate(l limbs, entire joints with their attached capsule 
 and ligaments. 
 
 SPECIAL INFECTIONS OF THE JOINTS. 
 
 The special infections of the joints usually can be differentiated 
 clinically from pyemic infections, and from each other, but bacterio- 
 logical study of the joint fluids or capsule may be necessary. Pyemic 
 infections of joints are referred to at p. 74. 
 
 Pneumococcic Infection usually is a complication of pneumonia 
 (70 per cent, of cases), but may occur from other sources, especially 
 otitis media. The knee and shoulder are most often attacked. There 
 is purulent effusion, and the signs of acute arthritis are present. 
 Treatment consists in aspiration of the fluid and injection of 2 per cent, 
 formalin-glycerin solution, and use of weight extension. Arthrotomy 
 and drainage should be done if symptoms are severe or persist. 
 The mortality is about 33 per cent. (K. Bulkley, 1914). Ankylosis 
 is not unusual, but formation of sinuses is rare. 
 
 Gonococcic Infection usually is secondary to a gonococcal urethritis 
 or its local complications. It occurs in less than 2 per cent, of 
 cases, and mostly in the male sex; almost invariably the joint con- 
 dition appears in the end of the third week (eighteenth to twenty- 
 second day) after the onset of gonorrhea. The polyarticular form 
 is rheumatic (i. e., synovial) in character, somewhat resembling 
 acute rheumatic arthritis; but the monarticular form is more like a 
 septic arthritis. In the former the small joints of the hands and feet 
 are oftenest affected; sometimes the sterno-clavicular joint. In the 
 monartictilar, form the knee, ankle, wrist, and elbow are oftenest 
 invaded. The joints become extremely painful, swollen, red, and 
 doughy to the touch. There is not much effusion. Endocarditis 
 is an occasional complication. Spontaneous fistulization is rare. 
 After gonococcic arthritis the joints are left in a more or less damaged 
 
472 
 
 DISEASES OF JOINTS 
 
 and sometimes seriously deformed state. Bony ankylosis is not 
 unusual. 
 
 Treatment. — If rest of the affected joints (the patient always being 
 confined to bed, and the primary infection receiving proper attention) 
 does not secure marked imi)rovement within forty-eight hours, the 
 joints should be opened, and irrigated with saline or formalin-glycerin 
 solution, and closed without drainage. There is too little effusion, 
 
 Fig. 489. — Post-typhoid ankylosis of 
 left hip, in a lad of sixteen years. 
 Dr. Harte'scase. (See Fig. 490.) Ortho- 
 pedic Hospital. 
 
 Fig. 490. — Result of subtrochanteric 
 osteotomy of left femur for bony ankylosis 
 in bad position. (See Fig. 489.) Ortho- 
 psedic Hospital. 
 
 as a rule, for mere aspiration and injection to be efficient. Usually 
 the disease is much shortened by joint irrigation; under conservative 
 measures the joints may remain acutely painful for weeks, and the 
 patient's health often is gravely affected, hectic fever and emaciation 
 developing. Vaccine therapy is of considerable value. Fuller (1905) 
 has proposed and practised drainage or extirpation of the seminal 
 vesicles which some regard as the focus which maintains the infection. 
 Typhoid Arthritis occurs during or after convalescence from typhoid 
 fever, usually about the third or fourth week of the disease. Its 
 
UNKNOWN INFECTIONS OF THE JOINTS 473 
 
 development may be overlooked, owing to the patient's apathetic 
 state. The hip is most often alVected (Figs. 4S!) and HIO) ; su|)i)ura- 
 tion and sinns i'ormation are not unusnal (perhaps from mixed infec- 
 tion), thongh as in pneumococcic and gonococcic arthritis ankylosis 
 may follow without frank sujjpuration. Pathological luxation may 
 occur. Ti/phoid .s-pondi/litis (p. (ilo) sometimes is seen, though a true 
 inflannnation of the vertebral joints is nnich rarer than a periarticular 
 fibrosis. 
 
 Subpyemic and Cryptogenous Arthritis. — In addition to these 
 special infections of joints, and to tuberculous and syphilitic joint 
 diseases, which are considered at p. 47(5 and 503, there are a number 
 of other systemic infections, the etiological organisms of which are not 
 known in all cases, but which sometimes are accompanied or followed 
 by inflammation of one or more joints, and in which it is very evident 
 that the general infection is responsible for the local inflammation, 
 either by direct action of its bacteria, or through the toxins derived 
 from these microbes. Such articular infections may be grouped 
 together conveniently, as is done by Marsh, as subpyemic infections, 
 some of them having a more or less evident etiology and symp- 
 tomatology (arthritis and scarlet fever, influenza, dysentery, etc.); 
 w^hile in others, such as "acute articular rheumatism," the joint 
 infection itself seems almost to constitute the disease. Acute rheu- 
 matic arthritis, unless some efficacious serum or vaccine is secured 
 soon, will become a surgical disease when physicians become thor- 
 oughly convinced that it is a form of pyemia. Immediate removal 
 of the pharyngeal tonsils, thought by some to be the portal of infec- 
 tion, has been adopted in a few cases. Or the surgeon may open, 
 irrigate, and close the first joint affected; or aspiration and injection 
 with formalin-glycerin solution (2 per cent.) may be done. 
 
 Probably the form of metastatic arthritis most often encountered is 
 that following infections of the pharynx, naso-pharynx, or tonsils. The 
 joint manifestations occur so long (several weeks) after the primary 
 lesion has healed that their inter-relation usually is overlooked. The 
 patients come to the surgeon with bony ankylosis, and tell him their 
 physician has been treating them for rheumatism. The history is 
 that very soon after exposure to cold or wet,^ sudden pain developed 
 in one or more joints; probably a chill occurred; the joint became 
 swollen, red, and tender; the patients lay in bed a long time in one 
 position; and finally when in the course of several weeks the acute 
 symptoms subsided, one or more joints were found to be stiff, and 
 have remained so since. A skiagraph will show bony ankylosis. 
 Now, acute rheumatic artliritis does not cause ankylosis, its symptoms 
 are rapidly relieved by salicylates, and the disease does not last more 
 than two or three weeks. 
 
 These acute metastatic joint infections should be treated by weight- 
 extension (to prevent deformity and if possible ankylosis), by aspira- 
 
 ^ This is to be regarded merely as the localizing cause of the joint lesions. The 
 infection which occurred two or three weeks previously is the original cause. 
 
474 DISEASES OF JOINTS 
 
 turn of the joint contents (to relieve pressure on the synovial mem- 
 brane thus preventing its destruction), and by injection of 10 to 15 c.c. 
 of a 2 per cent, formalin-glycerin solidion (to sterilize the joint). This 
 injection may have to be repeated once or twice after intervals of a 
 few days (Murphy, 1913). 
 
 There is, moreover, a still more obscure group of joint diseases, 
 which clinically give every evidence of being infectious, but the 
 true pathogenesis of which has not been established from a bacterio- 
 logical stand-point. These may be called cryptogenous infections of 
 joints, and include \arious "rheumatoid" conditions, which clinically 
 resemble infectious as distinguished from dystrophic arthritis (p. 452). 
 Among these, chronic rhemnatjc arthritis, a disease whose existence 
 I do not doubt, holds an important place; by it I understand the 
 
 Fig. 491. — Chronic rheumatic arthritis; age fifr\- \-(ar>; had acute rheumatic 
 arthritis as child and as girl. Orthoptedic Hospital. 
 
 damaged condition of joints which may persist after one or several 
 attacks of "acute articular rheumatism;" on such a joint may be 
 grafted, as on to any joint or set of joints whose resistance is below 
 par, dystrophic lesions. I believe Fig. 491 represents such a condition. 
 Still's Disease (1897), a chronic polyarticular affection of young 
 childhood, resembling atrophic arthritis in many respects, and accom- 
 panied ])y enlargement of the lymph nodes and spleen, and involve- 
 ment of the cervical spine, probably belongs among the cryptogenous 
 infections. So does the tuherculoiis rheumatism of Poncet (1903), 
 which is a subacute polyarticular infection, somewhat resembling in 
 onset "acute articular rheumatism," but probably due to endogenous 
 toxins of tubercle bacilli (Figs. 492 and 493). In this group of crypt- 
 ogenous infections also belong certain cases of arthritis which cease to 
 
VNKXOWX INFKCTIOXS OF TlIK JOINTS 475 
 
 tr()ul)k' till" palii'iit wlii'ii Uv is curod t)t" .sonic source ot" inl'cctioii which 
 iiijiy have been ncf!;lecte(l for yciirs; such are dental caries, pyorriiea 
 
 Fi(i. 492. — Tul)ciX'iilous rhcuinatisni in a girl of fi\-e .\-e:us. Acute onset in left ankle, 
 some weeks after an attack of scarlatina. Six months later left knee, wrist, and shoulder 
 liecame similarly affected; reacted to tuberculin. Photographed one year after onset. 
 (See Fig. 493.) " Orthopa;dic Hospital. 
 
 Fio. 493. — Patient shown in Fig. 492, one year later. Normal extension in left 
 rist. Knee still in plaster of Paris, and four years later not yet quiet. Orthopsedic 
 
 .•*„! 
 
 wrist. 
 Hospital. 
 
 alveolaris; sinus diseases; affections of the tonsils; empyema thoracis 
 (Fig. 494); affections of the lungs (here belongs pidmonary osteo- 
 
476 
 
 DISEASES OF BONE 
 
 arthropathy), intestines, appendix; genito-iirinary diseases in both 
 sexes, especially chronic semino-vesiculitis or prostatitis in the male, 
 and cervical lacerations in the female, etc. Cases of joint disease 
 concerned with one or more of the abo^■e infections are constantly 
 being seen, and are recognized by intelligent physicians; and some 
 remarkable results obtained by cure of the primary infection have 
 been reported by Marsh, Goldthwait, and others. 
 
 In chronic rheumatoid conditions always look for a source of 
 infection. 
 
 Fig. 494. — Pulmonary osteoarthropathy. Clubbed fingers four years after operation 
 for empyema (unhealed; . Age ten years. Children's Hospital. 
 
 Tuberculosis of Joints.' — Pathology. — In tuberculous arthritis the 
 primary lesion in almost all cases, especially in children, is in the 
 adjacent bone, and the synovial membrane lining the joint cavity 
 is invaded only secondarily. This was first definitely shown by 
 Nichols, of Boston, in 1898. The bacilli reach the bone ends through 
 the blood-stream, presumably from a preexisting focus in the bronchial 
 or mesenteric lymph nodes; and they lodge in the region of the epiphy- 
 seal cartilage rather than in the diaphysis of the bone for the ana- 
 tomical reasons stated at p. 438. The di.sease begins on one side or 
 other of the epiphyseal cartilage. An additional, and perhaps a better 
 reason for this localization of the bacilli is suggested by Ely (1911): 
 he recalls the well known fact that tubercle bacilli flourish where 
 red marrow exists (as in the epiphyses of growing bones), whereas 
 bone which contains yellow marrow (adult bones throughout, and 
 the diaphyses of juvenile bones) is almo.st immune to tuberculous 
 invasion; he also suggests that the immunity of cartilage and fascia 
 to tuberculous invasion is due to the fact that only in connective 
 tissues which have epithelial, epithelioid, or lymphoid cells, do tubercle 
 bacilli find a suitable soil for development, and that in this way the 
 marked affinity of tuberculosis for synovial membrane is to be ex- 
 plained. This theory of Ely's also explains why primary synovial 
 tuberculosis is so much less unusual in adults than in children, since 
 
 ^The tuberculous nature of these diseases was first clearly demonstrated by 
 Volkmann, in a classical paper published in 1879. 
 
PATHOLOGY OF TUBERCULOUS ARTHRITIS 
 
 477 
 
 the hones of tlie former do not aiford a suitahle soil for tlie develop- 
 ment of tuberculosis, owing to the absence of red marrow. 
 
 In tuberculosis of an ei)iphysis the lesion exists in th(! marrow, 
 the cells of this structure being grouped around the invading bacilli 
 in the form of histological tubercles; the bony trabeculne are then 
 destroyed, the centre of the tuberculous focus undergoes caseation, 
 and caries of the bone is said to exist; if actual liquefaction occurs a 
 cold absrcs's of bone is formed. The entire bone end is the seat of 
 a rarefying osteitis, the bony trabecuhe be ng much decreased in 
 size and strength, while the marrow spaces are increased. Formation 
 of sequestra is rather unusual ; when found they are small, and tyi)ic- 
 ally worm-eaten in appearance. Often there is a zone of sclerosed 
 bone immediately around the sequestrum or the central caseous 
 area, while outside of the sclerotic bone the rarefying osteitis, above 
 described, continues. Caries Sicca is a term used by Volkmann 
 (1867) to describe a rare form of joint disease now recognized as 
 tuberculous, which is seen oftenest in the shoulder and in which 
 gradual, quiet, fibrous ankylosis occurs, without swelling or other 
 evidences typical of tuberculous arthritis. 
 
 The articular cartilage resists for a long time invasion by the 
 spreading tuberculous process, and when the joint finally is entered 
 it is more often at the site of 
 attachment of the capsule than 
 in the centre of the articular 
 cartilage. But as the disease 
 progresses the articular cartilage 
 is gradually covered in by the 
 tuberculous granulation tissue or 
 "pannus," and is perforated in 
 numerous places, giving (Fig. 
 495) it a typical sieve-like (Volk- 
 mann, 1882) or "pepper-pot" ap- 
 pearance; and in advanced cases 
 the cartilage may be entirely de- 
 stroyed. 
 
 Before actual tuberculous inva- 
 sion of the joint cavity, there may 
 be slight serous synovitis with 
 effusion, from irritation due to the 
 focus in the neighboring bone end. 
 When the synovia has once been 
 
 invaded, or in the rare cases of primary synovial disease, the tuber- 
 culous process spreads rapidly throughout the joint, attacking and 
 perhaps destro}dng the ligaments, reaching out along adjacent tendon 
 sheaths and bursse, and causing a pulpy, gelatinous hyperplasia of 
 all the serous tissues attacked (gelatinous arthritis, Ashhurst, 1871). 
 Usually there is very little eflfusion, though "tuberculous hydrops" 
 occasionally occurs (Fig. 496). Either by condensation of fibrinous 
 
 Fiu. 495. — Head and neck of femur 
 excised for tuberculosis. Note "pepper- 
 pot" appearance of cartilage covering head 
 of femur; pathological fracture of neck: and 
 small sequestrum below. Children's Hos- 
 pital. 
 
478 
 
 DISEASES OF JOINTS 
 
 flakes, or by detachment of the tips of the villous synovial fringes, 
 so-called "rice-bodies" or "melon-seed bodies" may develop in tuber- 
 culous joints. By most authorities these are regarded as highly 
 characteristic of the tuberculous nature of the joint lesions: tubercle 
 bacilli frequently have been found within the rice-bodies, and their 
 inoculation into susceptible animals causes generalized tuberculosis. 
 
 If the tuberculous process extends to the skin surface, and a cold 
 abscess of bone discharges itself through a sinus, secondary infection 
 
 with pyogenic cocci is extremely apt to 
 occur. Before such seconrlary invasion 
 the walls of a sinus communicating with 
 a tuberculous focus are not themselves 
 the seat of tuberculosis; but when sec- 
 ondary infection is present the connec- 
 tive tissue which forms the walls of 
 such a sinus are studded with tubercles 
 (Ely, 1911). Secondary invasion with 
 pyogenic cocci may occur through the 
 blood-stream before any sinus forms; 
 such a complication is apt to hasten the 
 disintegrating process and encourage 
 formation of sinuses. 
 
 Healing occurs by the encapsulation of 
 the tu})erculous focus or its replacement 
 i)y fibrous tissue. If the joint cavity 
 has been invaded this implies more or 
 less firm fibrous ankylosis. In most 
 cases the tuberculous process merely 
 becomes latent, and is prone to become 
 active again if the joint is subjected to 
 unusual strain, or if the general health 
 becomes impaired, particularly })y the 
 development of pulmonary tuberculosis. 
 Clinical Course and Symptoms. — Joint tuberculosis is much more 
 frequent in children than in adults, arising especially during the 
 first decade of life. The spinal joints are those most often affected; 
 the knee and hip come next in order of frequency; while the joints 
 of the i^ot, elbow, and wrist are more frequently diseased than the 
 shoulder. In about one-third of the ca.ses in children a history of 
 traumatism can be obtained, two or three weeks previous to the 
 onset of joint symptoms; and this generally is regarded as having a 
 distinct etiological relation to the development of the disease. But 
 it mu.st be remembered that nearly all children sustain slight joint 
 injuries, yet comparatively few develop tuberculous arthritis; so 
 that it is necessary to assume a predisposition to tuberculosis and 
 the existence of a primary focus elsewhere in the body. The injury 
 which precedes the tuberculous joint symptoms rarely is severe; 
 fractures scarcely ever are followed by tuberculosis, and fractures 
 
 rc-iilotis h\-drop.s 
 
 Fk;. 49G.— Till; 
 of right knee. Age eight year.s. 
 Duration six months. For persist- 
 ence of .symptoms, excision of knee 
 was done five years later. (Dr. 
 Dickson's case.) OrthopEedic 
 Hospital. 
 
SYMI'TOMS OF TLHKRCVLOVS AinHRITIS 479 
 
 in tlu' tuhiTculous heal normally. Two exjjlanations are t)flVrc(l for 
 this: one is that the more severe injury arouses better defensive 
 action on the part of the patient ; the other is that sexcre lesions recjuire 
 careful and i)rolonji-c(l treatment, and healinj;, therefore, is more ai)t 
 to oceur than after a trivial injury which often is nejijlected. 
 
 Amonj; the earliest subjective symptoms of tuberculous arthritis 
 are disability and pain. The joint is used less, the joint is "favored," 
 and it fjives evidence of bein^ more easily tired than the normal 
 joint. StilVness ])resent on getting out of bed in the morning may 
 wear away during the day; but toward evening the joint again 
 becomes disabled, and this is evidenced by slight limp, and com])laints 
 of pain. Pain may be almost absent except when the joint is used; 
 but frequently a joint which is painless when the child is awake will 
 trouble it at night, causing restlessness, and on falling asleep and 
 relaxing its muscles the child will experience "starting ])ains" which 
 will rouse it momentarily from sleep with a "night-cry." Instead 
 of pain being felt at the diseased joint, it may be referred to the 
 peripheral distribution of the nerve supplying the joint: thus in 
 tuberculous spondylitis pain frequently is present in the epigastrium 
 (intercostal nerves), and in tuberculosis of the hip pain is referred 
 to the knee (obturator nerve). 
 
 Examination of the diseased joint at this early stage shows slight 
 but persistent muscular spasm. The muscles surrounding a joint 
 are supplied by the same nerve that supplies the joint, and irritation 
 of the joint causes reflex irritation of the adjacent muscles (Hilton's 
 law, 1877). The joint may be held absolutely rigid by the patient, 
 but in the earliest stages the most that can be detected is limitation 
 of motion in all directions: there is neither full extension, flexion, 
 abduction, adduction, nor rotation; and forcing any of these motions 
 causes pain. Comparison with movements of the corresponding 
 unaffected joint is imperative. The joint is held in the most com- 
 fortable position and is consistently protected by the patient: a 
 sore wrist or elbow is supported by the other hand, and if the hip or 
 knee is involved the sound foot may be put under the ankle of the 
 diseased limb and be used as a splint to prevent motion in the painful 
 joint. 
 
 There is tenderness to palpation directly over the joint, and per- 
 sistent tenderness of a bone end with evidences of articular irritation 
 is a valuable sign, l^nless the disease is advanced, or primarily 
 synovial in origin, there is rarely much thickening of the capsule or 
 synovial effusion. In superficial joints (knee, elbow, ankle) more 
 or less heat usually is appreciable, but in the hip this seldom can })e 
 detected. ^Muscular atrophy, an evidence of disuse, is a valuable 
 confirmatory sign of tuberculous arthritis; in early stages it sometimes 
 can be detected only by measurement, but in later stages, where 
 articular thickening is present and accentuates the atrophy, it is 
 apparent at a glance (Fig. 523). 
 
 With these local signs there is seldom much constitutional reaction. 
 
480 DISEASES OF JOINTS 
 
 The temperature may be raised 1° or 2° in the evening, and loss of 
 appetite and malaise may be present; but there is no acute inflamma- 
 tory state such as is seen in cases of septic arthritis. 
 
 As the disease progresses, the joint thickening increases, being of a 
 doughy, boggy consistency, and t\-pically spindle-shaped in outline. 
 The skin is pallid, and the affection well deserves the name "white 
 swelling" which has been applied to it for so many years. Spastic 
 contraction of the surrounding muscles passes into true contractures, 
 which will maintain deformity even if ankylosis is absent. Progres- 
 sive joint disintegration may lead to partial or complete dislocation; 
 and this usually is attended by relief from pain. Finally, by rupture 
 of cold abscesses, sinuses may develop, and usually this complication 
 is quickly followed by secondary infection, resulting in hectic fever, 
 and the gradual but progressive decline of the patient's general 
 health. 
 
 Diagnosis. — Symptoms of subacute arthritis in a child, from no 
 apparent cause, or following slight injury, and without marked 
 constitutional reaction, but persisting in spite of temporary rest, 
 always should excite a suspicion of tuberculosis. This suspicion is 
 strengthened by a family history of tuberculosis, either pulmonary 
 or osseous, and is made nearly positive if there is persistent elevation 
 of temperature of 1° or 2°, if the tuberculin tests (p. SI) are posi- 
 tive, and if there is no leukocj-tosis. Skiagraphic examination rarely 
 will reveal any bony focus so early in the disease as to be of much 
 value in doubtful cases, but a squaring of the epiphyses, particularly 
 at the knee, is regarded as characteristic of tuberculosis. 
 
 A sprain will cease to cause acute symptoms if the joint is put to 
 rest for two or three weeks; but a tuberculous arthritis always will 
 be roused to activity if joint function is resumed in so short a time. 
 A septic arthritis is more violent in its onset, is attended by much 
 more constitutional disturbance, and progresses to early suppuration 
 and joint disintegration; its course is run in days and weeks, while 
 that of a tuberculous arthritis extends over months and years. Acute 
 rheumatic arthritis is in most cases a polyarticular affection, is char- 
 acterized by high temperature, cardiac or pleural complications, 
 h;v'perleukocytosis, and marked local inflammatory reaction. It is 
 rare in young children. In syphilitic arthritis other signs of syphilis 
 nearly always can be detected. 
 
 A positive diagnosis of tuberculosis always can be made if tubercle 
 bacilli can be found in the synovial membrane, rice-bodies, joint- 
 fluid, etc., or if inoculation with these substances causes tuberculosis 
 in a susceptible animal. 
 
 Prognosis. — The most favorable cases are those of apparent osseous 
 origin in children, in which efficient treatment is instituted before 
 evidences of invasion of the synovia are demonstrable, and in which 
 the symptoms are so slight as scarcely to warrant a positive diagnosis. 
 These are the cases in which patients recover with joints which are 
 to all intents and purposes normal. After joint invasion is once 
 
TREATMENT OF TUBERCULOUS ARTHRITIS 481 
 
 tlc'iiioiistrahle, and in cases primarily synovial, the most that can be 
 hoped for is recovery with more or less impairment of motion; and 
 the more firm the ankylosis the less apt will the ])atient be to have 
 recurrence of the disease. After secondary infection the prof;;nosis 
 is t^loomier both as to function and life; and in adults all forms of 
 tuberculous arthritis are much more serious than in children. In 
 general terms it may be stated that from one-third to one-half of 
 j)atients with tuberculous arthritis die as a result of their joint lesions; 
 few indeed as a direct consequence (then mostly from hectic, amyloid 
 degeneration of the viscera, etc.), but many from tuberculous menin- 
 gitis, phthisis, or some intercurrent malady from which healthier 
 persons would have recovered. In cases ending in apparent recovery, 
 which often is merely latency of the tuberculous process, the course 
 of treatment must last from one to five years or longer; and other 
 patients must continue treatment until death removes them from 
 the surgeon's care. 
 
 Treatment. — The coiistitutional treatment of surgical tuberculosis 
 was discussed at p. 82; its value in tuberculous arthritis is inesti- 
 mable, and never should be forgotten. The most efficient local treat- 
 ment frequently is powerless to check the disease; and sometimes 
 constitutional treatment alone is able to restore a patient to health. 
 The surgeon must not overlook the fact that it is better to have a 
 healthy body with a stiff or deformed joint, than to have a straight 
 and comely joint without a body capable of sustaining life. If the 
 general health is good, joint function can be restored subsequently 
 by an orthopedic operation. Every hospital should have an open 
 air ward or at least a porch available for tuberculous joint cases, 
 where the advantages of constitutional and local treatment may be 
 combined for those most requiring such care. 
 
 Local treatment may be summed up almost in one word: Rest. 
 It is not known definitely how this acts, but a plausible theory is 
 suggested by Ely (1911): he contends that cure is effected by abolish- 
 ing joint function, because thus both red marrow and synovia become 
 atrophic and in the case of ankylosis entirely disappear; and where 
 they are not, tubercle bacilli cannot exist. 
 
 There are two chief methods by which joint rest is obtained: 
 fixation and traction. Fixation is secured by the use of splints, plaster 
 cases, braces, etc., the sole object being to abolish motion at the 
 diseased joint as effectually as possible; this not only relieves pain, 
 but has direct influence in checking the tuberculous process. By 
 traction is understood not so much actual extension on the limb 
 sufficient to pull the joint surfaces apart, as cessation of weight- 
 bearing and relief of pressure: it acts by relieving pain and securing 
 rest, but also prevents deformity which is prone to occur when the 
 weight of the bod}' is borne on the softened bone ends. Traction 
 is applied chiefly to the knee, hip, and spine; fixation alone usually 
 is sufficient for the upper extremity. 
 
 Whenever possible in the spine and lower extremity the advantages 
 31 
 
482 
 
 DISEASES OF JOINTS 
 
 of fixation and traction should be combined. This is best accomplished 
 by bed-treatment, so long as acute symptoms persist, regardless of 
 the stage of the disease. Recumbency at once removes the weight 
 
 Fig. 497. — Bradford frame. See text. 
 
 of the body from the diseased joints, and fixation is much more readily 
 secured. In children, the use of a Bradford frame (1890) (Fig. 497) 
 to which the body is strapped, provides fixation for spine, hip, or 
 
 Fig. 498. — On the roof garden of the Orthoptedic Hospital. Showing Bradford 
 frames with head and foot extension. 
 
 knee, in the most efficient manner. This frame is made of gas-pipe, 
 and is covered with tightly stretched canvas; it should be a little 
 longer than the patient and as wide as from one armpit to the other. 
 The child is fastened to it by a broad canvas apron covering chest 
 
TREATMENT OF Tl' liERCULOUS ARTIllilTlS 483 
 
 and alxloiiuMi, or hy straps crossing tlu' slionldcrs.' Tho franir thns 
 hecomi's a |)art of the child, and the two together can hv carried al)o\it 
 from room to room, or from ward to roof garden (Fig. 4!)N), thns 
 preventing the painfnl and harmfnl joint-movements necessitated 
 hy carrying the child in the arms or transferring it to a stretdier 
 and hack again to the bed. Weight-extension nsually is a desiral)Ie 
 adjnxant in secnring joint fixation, and is the most effectnal method 
 of ()\(Tcoming pain and nuiscnhir sj)asm, to which hitter factor 
 deformity in tiie earliest stages is (hie. Weight-extension always should 
 be applied in the axis of the deformity (Fig. 512), and as spasm 
 lessens the direction of the extension can })e gradually changed until 
 the normal ])osition is secured. (Ireat care must he exercised during 
 recumhent treatment to keep the foot at a right angle with the leg, 
 preventing the development of talipes equimis. 
 
 When all symptoms of arthritis (limitation of motion from si)asm, 
 l^ain, fever, etc.) have been absent for a month or more, recumbent 
 treatment may be discontimied. This stage is reached after two 
 to six months in cases coming under observation in the early stages 
 of the disease. Tf local treatment (fixation and traction) are now 
 recklessly discontimied in the erroneous idea that the joint is cured, 
 and if the patient is allowed to resume joint function, it will be only 
 a few weeks before all symptoms of arthritis return, and possibly in 
 aggravated form. It is absolutely imperative to guard the joint 
 against injury and strain by continuing for a long period fixation or 
 traction, or })otli, during ambulatory treatment. By the use of 
 plaster of Paris cases, braces, crutches, etc., both fixation and traction 
 (in modified forms) can be continued; and this should be done until, 
 by allowing gradual return of function (first limited motion, then 
 weight-bearing), the surgeon proves that the joint lesion has become 
 .so thoroughly encapsulated as not to be liable to cause recrudescence 
 of the disease. This period of ambulatory after-treatment extends 
 always through several months, usually through a year or more, and 
 often for many years. Only by making haste slowly can permanent 
 good results be achieved. If there is any reason (there are few good 
 reasons) why recumbent treatment is impossible when the patient 
 first is seen, ambulatory treatment with fixation and traction may be 
 employed from the start; but this is apt to promote ankylosis, and 
 deformity is very difficult to prevent. ^loreover, in many cases the 
 symptoms are so acute that rest in bed is an absolute necessity. 
 Yet I believe with Coudray (1911), that in no case should a manifest 
 tendency toward ankylosis be hindered; the joint should be kept in 
 good position, but attempts to preser^'e motion are extremely apt 
 to keep the disease active. The surest and most lasting cures are 
 those which follow ankylosis. 
 
 Treatment of Cold Abscesses. — If the joint be put at rest, and the 
 patient kept in the open air, the threatening abscess may cease to 
 
 ^ G. G. Davis uses also an uppei- frame, well padded and moulded to the body, 
 to hold the child against the lower frame. 
 
484 DISEASES OF JOINTS 
 
 enlarge, and in not a few cases gradually will disappear. Hence 
 these conservative measures should be given full trial. If the abscess 
 continues to enlarge, and threatens to approach the skin, with the 
 consequent danger of infection from the skin cocci, even before 
 spontaneous rupture makes such an infection sure, I think it is best 
 to expose the abscess wall by careful dissection tlirough overlying 
 healthy tissues, to incise the abscess, evacuate its contents, and wipe 
 the abscess cavity gently but thoroughly with iodoform gauze. I 
 cannot see that anything is to be gained by curetting the walls of the 
 abscess cavity, nor by attempts to "excise the sac," which in many 
 cases is an impossibility. The incision to reach the abscess is sutured 
 in layers, without drainage. Children should be etherized, but in 
 adults, local anesthesia is sufficient. In most cases (fifty-one out of 
 sixty, according to Starr, 1907), the incision heals without breaking 
 down at any point, and in only a very few cases does the abscess refill 
 and require a second evacuation. It is dangerous to leave a cold 
 abscess to itself until the overlying skin has become adherent and 
 reddened, since secondary infection from skin cocci is frequent, and 
 rapid joint disintegration, hectic, amyloid disease, etc., follow; and 
 it is still more dangerous to open a cold abscess without perfectly 
 aseptic technique, or to drain it by tube or gauze after incision, or 
 to allow it to discharge itself spontaneously. But sometimes the 
 patient is not seen until spontaneous rupture threatens, and secondary 
 infection already is present. Under such circumstances the abscess 
 should be evacuated by a small incision where it is pointing, but 
 should not be drained ; the puncture should be occluded with aseptic 
 gauze, and in many cases little or no subsequent discharge will occur, 
 the "hot" will gradually resume its character of "cold" abscess, 
 and eventually may be absorbed. Thus the formation of sinuses and 
 prolonged suppuration may be prevented. 
 
 Aspiration of a cold abscess is inferior to formal incision, because 
 it cannot be done satisfactorily until the ])ii- i> very close to the 
 surface and unless it is very fluid. A certain iiiuiilx.T of cures, however, 
 will follow aspiration and injection of a 10 per cent, iodoform-glycerin 
 emulsion. 
 
 Treatment of Sinuses. — In tuberculous arthritis sinuses nearly 
 invariably are an indication of secondary infection: if no secondary 
 infection is present (a fact which bacteriological investigation will 
 demonstrate), they usually will heal under rest and constitutional 
 treatment. I have had exceptionally good results from helio- 
 therapy: the sinuses are exposed to direct sunlight, beginning with 
 periods of five minutes twice daily, and increasing the length of the 
 exposures as rapidly as possible without producing sunburn. If 
 the sinuses fail to heal, and if discharge of pus is not profuse, they 
 should be filled with the bismuth paste of Beck (1905): one part of 
 bismuth subnitrate (arsenic free) to two parts of sterile amber vaselin. 
 This is heated in a water bath until fluid, and is injected into the 
 sinuses by a syringe which after being boiled, is rinsed in alcohol and 
 
TREATMENT OF TUBERCULOUS ARTHRITIS 
 
 4S5 
 
 ;ill()\v(>(l to (Irv before it is filled with the li(iui(l paste. The sinuses 
 ;ire filled as full as i)(>ssil)le. A skiaj,Tai)li, made after distending the 
 sinuses with this paste, will show their ori.uiu and raniifieations (Fig. 
 499). If pus should he dammed uj) hehind the i)ast(>. the iuereased 
 
 Fig 499 —Skiagraph of tubertulous arthritis of left hip, with sinus discharging on 
 outer surface of thigh; sinus has been distended with Beck's bismuth paste. Boy aged 
 ten years- coxalgia for six years. Abscess punctured three months before skiagraph was 
 made, because it was pointing and because there was secondary infection from skin 
 cocci. Orthopaedic Hospital. 
 
 local heat will cause the paste to melt, and it will be extruded from 
 the sinus spontaneously. The mode of action of bismuth paste is 
 not certainly known, but it causes marked improvement, the dis- 
 charge diminishing and the sinuses often closing in a comparatively 
 short time. If a firmer injection mass is desired, the following formula 
 
486 DISEASES OF JOINTS 
 
 (Beck's paste No. II) may be employed: Bismuth subnitrate (arsenic 
 free), 30 parts; amber vaseliii, 50 parts; paraffin, 10 parts. Or Mosetig- 
 Moorhof's iodoform })one-wax may be used (p. 435). Bismuth 
 poisoning has been observed in a few instances, so not more than 
 four or six oimces of Beck's paste should be employed in a child. 
 
 If profuse suppuration persists in spite of conservative measures, 
 it is probable that a sequestrum is present, and this may be removed 
 by curette or gouge. Formal operation in children rarely is advisable. 
 Injections of alcoholic solutions of iodin (2 to 10 per cent.) are useful 
 in overcoming secondary infection. 
 
 Operative Treatment in Tuberculous Arthritis. — It might be thought 
 that early excision of the diseased area would abort the disease, but 
 unfortunately it scarcely ever is possible to locate by skiagraphy 
 or otherwise an extra-articular focus; nor would what might be con- 
 sidered total extirpation of the focus amount to much more than 
 removal of the centre of an area infected far beyond what is indicated 
 by gross appearances. When once the joint itself is involved, only a 
 formal excision could remove all the disease, and in children such an 
 operation, which implies removal of the epiphyses, is productive of 
 such marked deformity and disability as to be generally condemned 
 by intelligent surgeons. Moreover, in children, the results of con- 
 servative treatment thoroughly carried out, as outlined above, are 
 so satisfactory, that operation presents no advantages in the early 
 stag&s of the disease. In adults, on the other hand, the results of 
 conservative treatment have proved so disheartening, chiefly through 
 their inability to endure confinement to bed, and their tendency 
 to develop phthisis, that joint excision or even amputation is the 
 accepted form of treatment. Ely (1911) claims that an excision which 
 will produce ankylosis and thus permanently abolish joint function 
 is all that is necessary to effect a cure; he asserts that it matters not 
 how little bone is removed, nor how much tuberculous material is 
 left, so long as ankylosis is obtained, as this in itself will cause dis- 
 appearance of synovia, which is the joint tissue on which in adults 
 tubercle bacilli almost solely subsist. But hitherto it has been the habit 
 of surgeons to remove as much diseased tissue as possible. In chil- 
 dren, excisions, if done, should be limited to the epiphyses of the 
 bones, the epiphyseal cartilages being rigorously respected, and any 
 focus in the metaphysis should be evacuated by the curette through 
 a perforation of the epiphyseal cartilage, and not by sawing off the 
 bone end until all diseased tissue disappears. Arthredomy or erasion 
 of joints, adapted especially to the knee, was introduced by Wright, 
 of Manchester (1881), and in this country by J. Ashhurst, Jr. (1889), 
 as a substitute for excision in children; it aims to remove all the diseased 
 soft tissues (synovia, ligaments, cartilages) without invading the 
 bones; and may be employed for the purpose of effecting ankylosis 
 when conservative measures fail to secure subsidence of symptomis. 
 Like excision, there is nothing specific in its action; it is merely a 
 method of joint disinfection. 
 
THE ATM EST OF TLBEliCV LOl'S AMOIJJSJS 
 
 487 
 
 Trcaiinenf of Anki/losis from Tiihrmilon.s- Arllirifl.s.- \s lias already 
 been indicated, ankylosis t'ollowiiif; tuherculous arthritis often inii)lies 
 merely a latency of the disease, though no doubt definitive cure 
 sometimes occurs. But owing to the frequency with which slight 
 trauma, even many years after ankylosis has occurred, may rouse 
 the dormant lesion into activity, the surgeon should be extremely 
 cautious in efforts to restore joint motion. If ankylosis has occurred 
 in good position, especially in the joints of the lower extremity, no 
 
 Fig. .jOO. — Ankylosis of hip from old 
 coxalgia, age thirteen years. Ortho- 
 paedic Hospital. 
 
 Fig. 501. — Same patient as Fig. 500; 
 one year after subtrochanteric osteotomy 
 of femur. Orthopsedic Hospital. 
 
 treatment should be adopted, as a rule. For deformity at the hip, 
 subtrochanteric osteotomy (p. 468) is the best treatment, as it divides 
 the bone where healthy (just below the lesser trochanter), and there 
 is very little risk of rousing the old disease, especially if the bone 
 section is made with a saw instead of by osteotome and mallet. A 
 puncture is made about two inches below the great trochanter, on 
 the outer side of the femur, with Adams's knife; this is passed 
 directly to the bone, and is then carried across its anterior surface, 
 and along this knife as a guide, Adams's saw is passed; the knife 
 
488 
 
 DISEASES OF JOINTS 
 
 is then withdrawn, and the femur is divided by very gentle sawing. 
 The limb is then brought into a position of abduction and nearly 
 full extension (Figs. 500 and 501). Tenotomy of the adductors may 
 be necessary to secure abduction. The limb is then fixed in this 
 position in plaster of Paris, and is treated as a recent fracture. At 
 the knee, formal excision (p. 469) usually will secure a useful and 
 straight limb, though still ankylosed; attempts at arthroplasty in 
 tuberculous knees are to be condemned. An ankylosed elbow causes 
 great disability even "if ankylosis has occurred at the best possible 
 angle, and excision may properly be done with the aim of restoring 
 motion. The same is true of the shoulder. 
 
 Fig. 502. — SkiaRraph of tulx-rculosis of left hii>joint. Boy, aged five years, 
 duration five months. Note al)duction and flexion of thigh; absorption of head of femur 
 and involvement of acetabulum. Orthopiedic Hospital. 
 
 Tuberculosis of the Hip. — Pathology — The primary lesion is in 
 the neck or head of the femur in most cases, but occasionally the 
 acetabulum or synovia is first involved. Acetabular and synovial 
 disease are intra-articular from the beginning; and a femoral lesion 
 very soon penetrates the joint, the epiphysis of the head being intra- 
 articular. Thus in all cases invasion of synovia occurs early, and in 
 many the acetabulum remains healthy for only a short period. There 
 is marked rarefaction of the bone, nearly all calcareous matter dis- 
 appearing; the skiagraphic picture (Fig. 502) is not unlike that of 
 round-celled sarcoma of bone in the total obliteration of all land- 
 
TUJJERCrLOSIS OF THE HI!' 
 
 489 
 
 marks. If wci^flit-beariii^ is contimicd, the acctiiimliiiii may he 
 enlarged iij)\v;ir(l and hackward (" waiidcriiij:; acctahuliim"), and 
 patlioloj^ical luxation may occur; if this is an early symptom in cases 
 in which wci^dit-hcariuj; lias not been allowed, it generally is due to 
 rupture of the cai)sule from intra-articular effusion. The head of the 
 femur may become very much altered in shape, or entirely absorbed; 
 and when secondary pyoj^enic infection is present, patholof^ical fracture 
 of the neck is not very rare (Fig. 495). The best result in such cases 
 is firm ankylosis (Fig. .'03). 
 
 Fig. 503. — ."t-kiagraijli of ankylosis of right hip following tuberculosis. Girl, aged 
 thirteen years; coxalgia at nine years: no symptoms for two years; healed sinus present 
 in groin. Note obliquely contracted pelvis. Orthopaedic Hospital. 
 
 Symptoms and Clinical Course. — When early symptoms of tuber- 
 culous joint disease (p. 479) point to the hip, the patient should be 
 attentively examined after removal of all clothing from the waist 
 down. Nearly 90 per cent, of cases are in children under ten years 
 of age. First the gait (bare-footed) should be studied : usually a slight 
 limp will be noted; and in the early stages the thigh is held in slight 
 flexion and abduction, causing flattening of the buttock and obliteration 
 of the gluteal fold on the affected side (Fig. 504). The patient is then 
 laid flat on his back on a firm table: measurements from the navel to 
 the malleoli may show apparent lengthening of the affected extremity; 
 this is due to its abduction, but if the healthy limb is placed in a 
 
490 
 
 DISEASES OF JOINTS 
 
 similar degree of abduction the discreijancy will disappear. Unless 
 there is marked bone deformation or dislocation there can be no actual 
 
 change in the length of the 
 
 Fig. 504. — Tuberculosis of the left 
 hip. First stage: flexion and abduc- 
 tion; flattening of buttock and oblit- 
 eration of the gluteal fold. Age five 
 years; duration two months. Ortho- 
 pcedic Hospital. 
 
 joint 
 
 limbs. Examination usually is best 
 begun by testing the motions of the 
 normal limb, making all the tests 
 with extreme gentleness, and aiming 
 to gain the child's confidence. Usually 
 the affected thigh is kept slightly 
 flexed (Pig. 505), and when an at- 
 tempt is made to bring it out 
 straight, the lumbar spine rises from 
 the table (Fig. 50()) because the hip 
 is held rigidly in flexion, and motion 
 is transferred to the spine. First 
 rotate the lower extremity gently to 
 and fro in its own axis, comparing 
 the motion in the two limbs; there 
 will be little or at least limited rota- 
 tion on the diseased side, and it will 
 be painful. Then try abduction of 
 the thigh, still keeping the limb as 
 fully extended as possible; on the 
 diseased side abduction usually is 
 markedly limited by the muscular 
 spasm. The range of flexion is next 
 investigated, first, by bringing the 
 sound thigh up against the abdo- 
 men, and then comparing this with 
 this usually is somewhat limited. 
 
 flexion in the diseased 
 
 but not so markedly as rotation and abduction. Next, abduction 
 
 with the thigh flexed to a right ang'e may be tested; this is always 
 
 Fig. 505. — Tuberculosis of right hip for nine months. Age three years. The hip is 
 held in a flexed position by muscular spasm, and the lumbar spine lies flat on the table. 
 (See Fig. 506.) OrthopEedic Hospital. 
 
 much decreased on the diseased side. Then the child is turned over 
 on its stomach, and the range of hyperextension is tested in each 
 hip by raising the knee from the table; this movement always is 
 
TUBERCULOSIS OF Till': H 1 1' 
 
 491 
 
 limited Dii the diseased side, and ulierc marked llexioii det'ormity 
 is present, it is manifestly unnecessary to test hyperextension. 11' 
 any of tliese motions are persistently, even if only very slightly 
 
 Fig. o()(J. — 'rulicrciilosis of iiKht \\\\^ (sec Fig. 505), showing archiiii; of luniJjar spine 
 when attoinpt is iiiadc to hriiifx tlic knee down on the tal)le. Motion occurs in the 
 hnnl)ar spine, not in tlie hip-joint. Ortlioptedic Hospital. 
 
 limited, and if there is a history typical of the onset of tuberculous 
 arthritis, the diagnosis may he considered established; and if an exami- 
 
 FiG. 507. — Deformity, following tuber- 
 culosis of hip: adduction and shortening 
 (six inches). Age sixteen years; onset 
 of disease at three years; healed sinuses. 
 No symptoms for the last eight years. 
 Orthopaedic Hospital. 
 
 Fig. 508. — Extreme exterior rotation 
 following tuberculosis of hip. Age twelve 
 years. Duration four years; sinuses still 
 open. (Dr. Alexander's case.) Episcopal 
 Hospital. 
 
 nation such as above indicated were systematically made by the 
 physician first called to attend the patient, and if proper treatment 
 were instituted, valuable time would be saved. Only too frequently 
 
492 
 
 DISEASES OF JOINTS 
 
 the family physician makes no physical examination at all, or only 
 a partial one, hampered by the patient's clothing; and treatment 
 
 for a sprain or for rheumatism is pre- 
 scribed, when a very little more trouble 
 would have enabled a correct diagnosis 
 to be made. In the rare cases where 
 the signs are so slight as to render 
 a positive diagnosis hazardous, the 
 surgeon will consult his own and the 
 patient's interests much better by 
 enjoining recumbent treatment for a 
 week or two, than by making light 
 of the malady. 
 
 At a later stage of the disease, the 
 early deformity of abduction is replaced 
 l)y adduction, possibly owing to atrophy 
 of the iliopsoas which lies closest to 
 the joint, and the unapposed action 
 of the adductors. In efforts to walk 
 the patient has to bring the lower 
 extremities parallel, and as the dis- 
 eased limb is fixed in adduction, the 
 healthy limb must be abducted to 
 correspond; this causes a descent of 
 the pelvis on the unaffected side, and 
 apparent shortening of the diseased 
 extremity. But if the healthy limb 
 is placed in a similar attitude of 
 adduction, the measurements will be 
 found the same, unless bone destruction or dislocation is present. 
 The deformity of flexion and adduction, in this which is called the 
 second stage of "coxalgia," may be due in part to intra-articular 
 
 Fig. 509. — Cold abscess of left 
 thigh, from tuberculosis of hip. 
 Sequestrum discharged later. Age 
 four years; duration three years. 
 Orthopaedic Hospital 
 
 Fig. SlO.^GIuteal abscess in coxalgia. (Dr. Hodge's case.) Children's Hospital. 
 
 changes, but most of it is due to muscular contractures which may 
 be overcome by joint fixation and traction. 
 
TUBERCULOSIS OF Till': /III' 493 
 
 At a still later stage of the disease the patient may come under 
 observation with cold abscess or simises, and with ankylosis in almost 
 any jjosition fFij^s. '){)7 and 508), or with patholoj^dcal luxation. Told 
 abscesses and sinuses usually are in direct comnuuiication with the 
 joint cavity, but occasionally are due to extra-articular perforation 
 of the l)one. The abscess may ])()int at any part of the thifi:h, but 
 
 Fig. 511. — Adductor ahscess in coxalfria. Ago six years. C'oxalgia for one j'ear. 
 Abscess for four weeks. Orthopaedic Hospital. 
 
 the most frequent site is on the outer side (Fig. 509); or a gluteal 
 abscess (Fig. 510) may occur, usually from perforation of the poste- 
 rior capsule. x\bscesses or sinuses in the adductor region (Fig. 511) 
 usually are an eA'idence that the acetabulum is involved, as, accord- 
 ing to Vincent (1895) is the occurrence of adduction as the primary 
 deformitv. 
 
 Fig. 512. — Bed extension for coxalgia with flexion deformity. Note the high 
 cradle to keep the bed-clothes ofT the foot. Episcopal Hospital. 
 
 Diagnosis. — Not every case of arthritis of the hip is tuberculous, 
 even io children, and where doubt exists as to the etiological factor, 
 other aids may be called in to assist the clinical diagnosis, such as the 
 tuberculin tests, estimation of the leukocytes, and skiagraphy. Nor 
 
494 
 
 DISEASES OF JOINTS 
 
 should the surgeon forget that other aflFections besides arthritis may 
 cause rigidity, flexion, adduction, etc. Among such may be mentioned 
 inguinal or femoral adenitis, psoas abscess (p. 607), and even appendi- 
 citis. Attention to the clinical history and physical signs will exclude 
 such affections as fracture of the cervix femoris, congenital or trau- 
 matic dislocation of the hip, coxa vara, and deformity from infantile 
 arthritis. 
 
 Treatment. — Recumbency should be insisted on in all early cases, 
 with weight extension of two or three pounds applied in the axis of 
 the deformity (Fig. 512). Sufficient fixation usually is secured by 
 
 Fig. 513. — Thomas hip brace. 
 Episcopal Hospital. 
 
 Fig. 514. — Thomas hi]) brace; 
 rear view. 
 
 strapping the body to a Bradford frame. If this cannot be procured, 
 a binder's-board splint or light plaster cast may be applied to the 
 hip and pelvis, weight-extension being used in addition. In most 
 cases, after a week or two, muscular spasm disappears and full ex- 
 tension may be secured. The temperature should be recorded twice 
 daily, in this as in all acute tuberculous conditions; it forms a valu- 
 able guide as to the progress of the local lesion. After one or two 
 months of recumbency examination may disclose an apparently nor- 
 mal joint, and the temperature curve may be quite satisfactory; 
 but this merely indicates that the disease is latent, not that it is 
 cured. 
 
TUBERCULOSIS OF THK J/Il' 
 
 49.5 
 
 \\'lii'ii s\ luptums have hocn al)sent for a luoiitli or more, aiiil)ula- 
 tory treatment may be cautiously tried. In this, joint fixation may- 
 be jixadually relaxed, but weight-bearing should be prevented for a 
 long time to come. \'arious braces are in use for this stage of treat- 
 ment: with all, a high shoe is worn on the healthy side, and crutches 
 are used, allowing the diseased limb to swing free of the ground. The 
 brace of II. O. Thomas (1875) (Figs. 513 and 514), prox idea fixation 
 at the hi]), and traction is secured by the weight of the limb; l)ut it 
 is impossible for the })atient to sit down with the brace on, and 
 the limb may rotate within the brace, giving rise to unsuspected 
 
 H^:i ' 
 
 5 
 
 ^^^^H ^ ^M^ 
 
 I 
 
 
 1 
 
 ^H/^K^^ft ^ |k.'-< 
 
 i 
 
 
 1 
 
 jJTjHM^^M^sli^l^HHKi^ 
 
 m 
 
 Fig. .515.- 
 
 -Taylor hip brace. Episcopal 
 Hospital. 
 
 Fig. 516. — G. G. Davis's brace for 
 coxalgia. Orthopa?dic Hospital. 
 
 deformity. About 1855 H. G. Davis introduced the method of traction 
 in ambulatory splints; a modification of this, introduced in 1873 by 
 C. F. Taylor (Fig. 515), consists of a pelvic band, passing around the 
 pelvis between the anterior superior iliac spines and the level of the 
 great trochanters, to which is attached a long outside iron extending 
 below the foot beneath which it forms a stirrup; to the stirrup traction 
 straps are fastened from the foot, counter-extension being provided 
 by a perineal strap. Movements of flexion and extension are per- 
 mitted at the hip, as the outside iron is jointed below the pelvic band; 
 this allows a sitting posture to be assumed. A more efficient brace 
 
496 DISEASES OF JOINTS 
 
 is that of G. G. Davis (Fig. 510), in which besides a perineal strap for 
 counter-extension, as in the Taylor brace, an inside iron is added 
 which supports a well-padded bar passing from one side iron to the 
 other beneath the tuber ischii; on this bar the patient sits, absolutely 
 preventing weight-bearing on the diseased joint, while the foot exten- 
 sion keeps the lower extremity taut, aiding the weight of the limb 
 in securing traction. If braces cannot be secured, a spica bandage 
 of plaster of Paris may be applied to the thigh and pelvis, preferably 
 fixing the knee and ankle also; and with a high shoe on the sound side, 
 and crutches, the patient may do well, though a well-fitting brace is 
 much more cleanly and comfortable. Usually it is well for the brace to 
 be worn night and day at first, until it is certain that no recurrence of 
 symptoms is to be feared, when it may be left off at night. While 
 a patient is wearing a brace, he should be seen by the surgeon every 
 two or three weeks; and the surgeon should himself see, personally, 
 that the brace fits comfortably and is efficient. If he is unwilling 
 or unable to undertake the responsibilities of mechanical treatment, 
 he should retire from the case. 
 
 If it is found that under ambulatory treatment symptoms of 
 coxitis return, recumbent treatment should be resumed, and carried 
 out as already indicated. When, however, ambulatory treatment 
 succeeds, joint fixation may be gradually dispensed with. If eight 
 months or a year are passed without any symptoms whatever of 
 joint trouble, it probably will be safe to discard the brace, but a 
 high shoe on the sound side and the use of crutches should be insisted 
 on for a much longer period. Then the high shoe may be abandoned, 
 and crutches alone used, until by very gradual stages weight-bearing 
 is proved safe. 
 
 I am well aware that some orthopedic surgeons at present are 
 opposed to such conservative measures, and prefer to follow the 
 example of Lorenz (1906), in treating all early cases of coxalgia by 
 weight-bearing, fixing the joint in the attitude of deformity by a 
 gypsum splint, and abolishing recumbency and traction entirely 
 from their plan of treatment. But the plan here recommended seems 
 to me the most rational when the pathology of the lesions is con- 
 sidered, and is still employed by the majority of judicious surgeons 
 in this country. Great Britain, and France; and I am convinced that 
 if rigorously employed from the earliest stage, it will cure a much 
 larger proportion of patients without ankylosis than will the method 
 of Lorenz, though the course of treatment may be longer. 
 
 The treatment of cold abscess and sinuses, with secondary infection, 
 has been so fully discussed at p. 4S4, that little need be said here. In 
 almost all cases recumbent treatment, and heliotherapy, alone or with 
 bismuth or iodin injections, will cause sinuses to close eventually. Very 
 rarely it may be necessary to remove a sequestrum or some carious 
 bone by the curette; then the cavity should be filled with iodoform 
 bone-wax (p. 435). Almost never is formal excision necessary or 
 desirable in children, and then only to avert death from sepsis, and 
 
rVHERCrLOSIS OF THE Ull' 
 
 497 
 
 as a less severe remedy than amputation, I liave done only two 
 excisions of the hip, employed as a last resort in cases of profuse 
 suppuration and prolonged liectic: one hoy (Fig. 40")) recovered with 
 the usual shortened and detormed, tiiough useful limh (Figs. ")17and 
 518); the other, though temporary improvement was secured (Fig. '.V2), 
 died two months later from tuberculous meningitis. Excision of the 
 hi}) for tuberculosis siiould l)e regarded merely as a method of joint 
 
 Fig. 517. — Ridult (jf excision of hip for 
 tuberculosis, in a boy of fourteen years, 
 one year after operation. (Dr. H. C. 
 Deaver's case.) (See Fig. 518.) Epis- 
 copal Hospital. 
 
 Fig. 518. — Excision of left hip for 
 coxalgia; age fourteen jears. Left hij) 
 in slight adduction; apparent shortening 
 three inches, actual shortening one and 
 a half inches; still uses crutches; wound 
 dry but scabby; one j^ear after operation. 
 Episcopal Hospital. 
 
 disinfection (Coudray, 1911), and should be as conservative in extent 
 as is possible with such end in view. An anterior incision is best, 
 as originally advocated by Hueter (1878), and later adopted by 
 R. W. Parker; this incision is made on the outer side of the sartorius, 
 displacing the rectus and ilio-psoas to the inner side (Barker, 1888) ; 
 as much synovia should be removed as possible. In very septic cases 
 the posterior longitudinal incision is preferable. This was u.sed by 
 C. White, of Manchester (1769), and was known during the nineteenth 
 32 
 
498 
 
 DISEASES OF JOINTS 
 
 century by Langenbeck's name. After detaching the muscles from 
 the great trochanter the femur is divided below this process, the 
 entire upper end being removed; the acetabulum also is gouged away 
 if necrotic. Though the immediate mortality of the operation is 
 only about 5 per cent., yet when employed for the cases here described 
 as suitable for such treatment, the ultimate death rate is from 20 
 to 25 per cent. If employed in less severe cases in which it is not 
 necessary, the death rate will, of course, be less. Amputation occa- 
 sionally may save a life after 
 excision and re-excision have 
 failed. After the operation 
 recumbent treatment with 
 fixation and traction is con- 
 tinued until latency of symp- 
 toms indicates the propriety 
 of passing to ambulatory 
 treatment. Ankylosis should 
 be encouraged. ' Ely (1911) 
 thinks the benefit of excision 
 in hip disease is due to the 
 luxation of the femur which 
 often results, thus perma- 
 nently abolishing the joint as 
 such, as effectually as would 
 ankylosis (p. 481). 
 
 In adults, in whom tuber- 
 culosis of the hip is rare, ex- 
 cision is more often required, 
 but, fortunately, the resulting 
 disability is less. 
 
 Tuberculosis of the Knee. 
 — This is the most frequent 
 form of tuberculous joint dis- 
 ease in adults, in whom the 
 primary lesion often is syno- 
 vial; but the knee is often 
 attacked in children also, 
 and in them usually the 
 femur, tibia, or patella is 
 first involved. In the knee, 
 as in the elbow, local signs of arthritis are much more marked 
 than in the hip, consisting in heat, dusky redness, typical fusiform 
 swelling, and occasionally in intra-articular eft'usion. Usually, how- 
 ever, enlargement of the joint is due to fungus granulation tissue, and 
 though it may seem as if fluctuation was present, aspiration will fail 
 to demonstrate fluid. The patella does not float, but early becomes 
 fixed more or less firmly to the condyles of the femur (Fig. 519). 
 The knee is flexed, and contractures of the hamstrings develop. 
 
 Fig. 519. — Skiagraph of tuberculous arthritis 
 of knee; age thirty-seven years; duration seven 
 years. Same patient as in Fig. 520. Episcopal 
 Hospital. 
 
TUBERCULOSIS OF THE KNEE 
 
 499 
 
 In iulvaiurd cases iiostcrior sul)luxati()ii of tlio tibia (occurs, usually 
 accoinpaniod also hy rotation outward. Starting pains are very 
 annoying, and the patient lies curled uj) on the diseased side, his 
 whole attention apparentl\- concentrated in protecting the painful 
 joint from injur>- or motion. Cold abscess is rarer than in hip disease, 
 and sinuses more freciuently are of extra-articular origin. 
 
 Treatment. -The treatment consists in local rest, secured in acute 
 cases by recumbency with splinting and weight-extension. In less 
 severe cases the fixation 
 by plaster of Paris without 
 traction may suffice, and 
 if the gypsum is renewed 
 every four or five weeks 
 gradual decrease of the de- 
 formity may be secured. 
 Weight - bearing usually 
 should be allowed before 
 motion at the knee, but 
 for some months after am- 
 bulatory treatment is com- 
 menced it is safer to employ 
 a traction brace, much the 
 same as in hip disease, 
 with a high shoe on the 
 healthy foot, and crutches. 
 If conservative treatment 
 is persisted in for a year, 
 and the disease fails to be- 
 come latent, the question 
 
 of operative treatment may 
 
 arise : in children below the 
 
 age of puberty all that 
 
 should be attempted is 
 
 erasion of the joint (arth- 
 
 rectomy, p. 486); and 
 
 though by resort to this 
 
 operation the disease may 
 
 not be permanently cured, 
 
 and though, as is frequent, 
 
 flexion deformity develops 
 
 after operation, it may be 
 
 possible by its aid to tide 
 
 the patient over the years 
 
 of childhood until formal excision can be safely done. In adults the 
 
 results of conservative treatment are very disappointing (Fig. 520) ; 
 
 if, after judicious trial of this for some months, no improvement 
 
 occurs, or if the disease constantly lights up afresh when ambulatory 
 
 treatment is adopted, excision of the knee should be done; and m 
 
 Fig. 520. — Skiagraph of tuberculous arthritis of 
 knee, showing destruction of external condyle of 
 femur, external tuberosity of tibia and perforation 
 of cartilage of tibia. Age thirty-seven years; 
 duration seven j^ears. Probably synovial in 
 origin. Treated by excision. Episcopal Hospital. 
 
500 
 
 DISEASES OF JOINTS 
 
 practically all cases in adults with sinuses or secondary infection, 
 early excision will give the best results (Fig. 521). The ojjcration 
 has been described at p. 469. Ankylosis should be firm in eight 
 to ten weeks. Even if excision fails to cure the disease at once, 
 which rarely is the case, the surgeon must not conclude that immediate 
 amputation is necessary; by persistence in conservative measures, firm 
 ankylosis and healing of sinuses may yet occur; or a re-excision may 
 be more successful. Amputation should be regarded as the last 
 resort, chiefly adapted to the very old. By excision the limb will be 
 shortened from one-half to two inches. During convalescence from 
 operation the tendency to development of genu \arum must be 
 guarded against, as well as the tendency of the femur to ride for- 
 ward on the tibia. The patient should wear an orthopedic apparatus 
 to fix the knee for a year. The immediate mortality of the operation 
 is about 5 to 10 per cent. 
 
 Fig. 521. — Specimen from excision of left 
 knee for tuberculosis. (See Figs. 519 [and 
 520.) Episcopal Hospital. 
 
 Vic. 52l'. — Tul)t'rcul<)sis of left 
 ankle-joint. Episcopal Hospital. 
 
 Tuberculosis of the Ankle and Tarsus. — The diagnosis sometimes 
 is difficult in children or adolescents, in whom painful flat-foot (p. 547) 
 may be the primary symptom. The astragalus and calcaneum are 
 the bones most often affected, but owing to the proximity of so 
 much synovial membrane (Fig. 165), early joint invasion occurs (Fig. 
 522), and fistulization with secondary infection is very common. 
 
 Treatment. — Treatment, even when the diagnosis is only tentative, 
 should be by rest and cessation of weight-bearing, secured by a gypsum 
 case and use of crutches. This usually is sufficient in children, in 
 whom sinuses soon close, and erasion rarely is required. If motion 
 is prevented by a suitable brace, weight-bearing may be resumed a 
 few months after cessation of active symptoms. In adults, on the 
 other hand, time should not be lost in conservative treatment unless 
 improvement is progressive; if the disease seems stationary, and 
 especially if the foot grows worse, erasion or excision should be resorted 
 
TUBERCULOSIS OF THE- F.LIiOW 
 
 501 
 
 to without (Ichiy. The entire astragalus should he renioNi-d, and as 
 much of the t ulxrculous soft parts as p()ssil)le. Usually the sur},'eon 
 
 Fig. o2'.i. — Tiil^erculosis of elbow in a 
 child of four years, showing typical 
 fusiform .swellinji; also tuberculous spon- 
 dylitis, and tuberculous osteomyelitis 
 of left forearm and hand with sinuses. 
 This condition iseuphonioiisly descrilied 
 as the "moist rot." Children's Hospital. 
 
 Fig. 524. — Tuberculosis of elbow. 
 Age seven years; duration four years; 
 sinuses for four months. Also tuber- 
 culous cervical adenitis. (See Fig. 525.) 
 Orthopedic Hospital. 
 
 finds that he has delayed too long, and that while this con- 
 servative operation may improve matters for a while, amputation 
 eventually will be necessary. 
 Tuberculosis of the Elbow 
 is much more frequent in 
 children than in adults. The 
 primary lesion is more often 
 in the ulna or humerus than 
 in the radius. Joint invasion 
 is rapid, and typical fusi- 
 form enlargement results 
 (Fig. 523). Fistulization is 
 difficult to prevent (Fig. 
 524), and cure seldom oc- 
 curs except by ankylosis, 
 and it is better, especially 
 in children, to encourage 
 ankylosis and closure of 
 sinuses than to resort to 
 precocious excision (Fig. 
 525). No effort should be 
 
 made to restore motion until all symptoms have been absent for 
 many months. Then an excision or arthroplasty may be done. 
 
 Fig. 525. — Tuberculous ell)ow, fibrous anky- 
 losis, sinuses healed. Age ten years. Three and 
 a half years after Fig. 524. 
 
502 
 
 DISEASES OF JOINTS 
 
 Tuberculosis of the Wrist. — This is rare in children; immobilization 
 promptly employed and long continned usnally prodnces a cure with 
 only moderate limitation of mot on. In adults sinuses are prone 
 to form, and amputation is the usual termination, though erasion 
 should be tried first. Formal excision of the wrist is very rarely 
 advisable (p. 470); firm fibrous ankylosis is songht, and the hand 
 seldom is verv useful. 
 
 Fig. 526. — Syphilitic arthritis of left elbow. 
 Ago fourteen years: duration two years. Also 
 interstitial keratitis and slight sabre-blade 
 tibia. Orthopsedic Hospital. 
 
 Fii,. .j_'7. — S\ jiliilitir arthritic of 
 both knees. Age thirteen year.s; dura- 
 tion five months. Orthopsedic Hos- 
 pital. 
 
 Tuberculosis of the Sacro-iUac Joint is very rare, especially in 
 children. The symptoms are pain, sometimes radiating down the 
 sciatic nerve, localized tenderness over the affected joint, and a 
 peculiar feeling of insecurity in the pelvis on attempts to walk. When 
 standing, the body is inclined away from the diseased side, as in 
 " sciatica. " Examination shows no involvement of the hip or vertebrae ; 
 hyper-flexion of the hip on the diseased side occurs to the normal 
 extent unless the knee is kept extended, when it will be impossible 
 to flex the hip as far on the diseased as on the healthy side, since 
 muscular spasm will be roused by traction on the ischium through 
 the tense hamstrings. Pressing the iliac crests together, and attempts 
 at antero-posterior motion in the pelvic joints cause pain. In advanced 
 cases swelling over the dorsal or pelvic surface of the joint occurs, 
 and suppuration may develop, with sinuses posteriorly or in the 
 inguinal or adductor regions. 
 
 Treatment. — Recumbency, with weight-extension for many months, 
 is required. No form of apparatus is satisfactory in preventing 
 weight-bearing at the sacro-iliac joint, and recurrence of symptoms 
 
TUMORS OF JOINTS 503 
 
 is not iimisual wlieii ambulaton' treatment is att('nij)t('(l. A few 
 recoveries have i)een reported after resection of tiie joint, but even 
 in adults tiiis should be reserved until conservative measures have 
 proved inelfectual. l^i((pie (1910) reports seven resections of the 
 sacro-iliac joint for tuberculosis: two patients were cured, three were 
 recovering- ("nearly cured"), one died of cachexia, and the last had 
 amyloid dcireneration of the viscera and death was anticipated. 
 
 Syphilis of the Joints. — Syphilitic arthritis is not very rare in cases 
 of hereditary lues, but often, especially in the acquired form of the 
 disease, is not reco^ijnized. In its clinical aspects the disease nuich 
 reseml)les tuberculous arthritis, especially of the primary synovial 
 type, but pain is less severe. The diagnosis usually is made from 
 concomitant evidences of syphilis (Figs. o2() and 527), and is confirmed 
 by the AVassermann reaction and results of antisy})hilitic treatment. 
 If the joint is painful, suitable apparatus should be i)roNided. 
 
 TUMORS OF JOINTS. 
 
 Tumors of the joints, except those developed from the neighboring 
 bones, are quite rare. 
 
 Lipoma Arborescens is the name given by Volkmann (1882) to 
 a synovial or subsyno\ial growth in which fatty deposits occur. It 
 is observed oftenest in the knee, along one side of the tendo patelhe, 
 but also occurs in the shoulder. It is regarded by Poncet, Marsh, 
 Ely, and Whitman as tuberculous in nature, and there is no doubt 
 that sometimes it is; but it is better to consider it, with Nichols 
 (1907), a hypertrophic synovial change which may occur in various 
 joint afl'ections. The fatty out-growth is more or less pedunculated, 
 is palpable through the skin as an ill-defined mass, and interferes 
 with the functions of the joint without producing very acute symptoms. 
 The best treatment is excision of the growth. 
 
 Sarcoma. — Primary sarcoma (endothelioma) of joints is rare. It 
 begins in the synovia or subsynovial connecti^'e tissue. Lejars and 
 Rubens-Duval (1910) have collected 16 cases, 13 of which occurred 
 in the knee. This is one of those neoplasms where transition from 
 epithelioid to sarcomatoid tissue is best observed. The clinical 
 symptoms somewhat resemble a subacute infectious arthritis, and the 
 diagnosis usually depends on microscopical examination of an excised 
 specimen. If the tumor recurs after local extirpation, amputation 
 should be done. 
 
CHAPTER X\\ . 
 
 ORTHOPEDIC SURGERY. 
 
 Orthopedics, from the Greek words oaf^o; and ~«^c, meaning lit- 
 erally a straight child, is that part of surgery which deals with the 
 correction of deformities, either congenital or acquired. So many 
 surgeons, during the last fifty years or more, have devoted their exclu- 
 sive attention to this subject, that the practice of orthopedic surgery 
 is now recognized as a specialty of equal rank with gynecology or 
 genito-urinary surgery. In the limits of a text-book on general sur- 
 gery, therefore, it is manifestly impossible to do more than provide 
 an outline of the subject, and inculcate the general principles which 
 underlie its practice. 
 
 CONGENITAL DEFORMITIES. 
 
 Congenital Absence of Bones is not very rare. Those most often 
 deficient are the radius, and the tibia or fibula. Sometimes the outer 
 portion of the foot is absent along with the fibula, or a portion of the 
 hand absent with the radius. The exact diagnosis often depends on 
 skiagraphy. The hand or foot deviates toward the side where its 
 support is lacking. In infancy malposition may be prevented or 
 corrected by splints, or other apparatus. Often during childhood 
 or adolescence it becomes necessary to operate for the correction of 
 deformity, or to improve function. In the foot, some form of arthro- 
 desis (p. 528) usually will be required to give stability in walking,' 
 while in the upper extremity it may seem desirable to lengthen con- 
 tracted muscles and tendons, and do osteotomy or resection of the 
 existing bone for cosmetic effect, though function can seldom be 
 improved. 
 
 Osteoplastic Operations. — After resection of a large part of the 
 diaphysis of a bone, for osteomyelitis or tumor, the limb often is left 
 in a helpless condition, much as in the cases of congenital deformity 
 noted above. When the shaft of the tibia has been excised, and fails 
 to regenerate, the upper end of the fibula may be moved over later 
 to a socket cut in the upper epiphysis of the tibia (Hahn, 1S84); 
 in cases reported by Nichols (1904), Huntington (1905), and others, 
 the fibula underwent hypertrophy and supported the weight of the 
 body very well. In other cases a portion of the diaphysis of the femur, 
 
 ^ Wille (1909) in a case of congenital absence of the fibula did arthrodesis by 
 driving a fibula (obtained from an amputated leg) up from the sole, through the 
 calcis, astragalus, and tibia, and obtained a fair result. 
 
CONGENITAL DEFORMITIES 
 
 505 
 
 IniuuTiis, or otluT long bone, lias hocn replaced immediately by 
 traiisi)laiitiiig a jxtrtioii of tlu> patient's tibia, ent long enongli to 
 fill the defect, and about half an inch in diameter. This "trans- 
 plant" must be brought into contact, 
 at least at one end, with healthy bone, 
 containing Ibnersiaii systeins, so that 
 the osteoblasts lining these may grow 
 along the channels in the transplant, 
 and thus lay down new bone in place 
 of that contained in the transj)lant, 
 which is slowl\' absorbed by the osteo- 
 clasts. If the transplant is not brought 
 into contact with a healthy Haversian 
 system, it will not l)e j)ermeated by 
 osteoblasts, but will be gradually ab- 
 sorbed and the operation will be a 
 failure (Murphy, 1912). Many sur- 
 geons prefer to preserve the perios- 
 teum of the transplant, thinking it 
 favors bone growth. I have always 
 removed the periosteum before cut- 
 ting the transplant. 
 
 Congenital Absence of Muscles 
 (Fig. o2<S), which is quite rare, seldom 
 entails much disability; when it does, 
 it usually is possible to improve function by tendon transplantation 
 (p. 525), or insertion of artificial ligaments (p. 529). 
 
 Fig. 528. — Congcnittil abscrife of 
 costal portion of right pcctoralis 
 major, in a girl of six years. No 
 disability. Slight scoliosis. Ortho- 
 paedic Hospital. 
 
 Fig. 529. — Supernumerary digits, sLx toes on each foot. Age seven months. Also 
 had six fingers on each hand, but the extra fingers were amputated at birth. Episcopal 
 Hospital. 
 
 Supernumerary Fingers or Toes (Polydactylism) (Fig. 529) usually 
 require amputation; special care should be paid to hemostasis, as 
 deaths in infants from secondary hemorrhage have been reported. 
 
506 
 
 ORTHOPEDIC SURGERY 
 
 Malformations involving the metacarpal or metatarsal bones seldom 
 can be appreciated without a skiagraph (Fig. 530), and require special 
 types of operation. 
 
 Fig- 530. — Skiagraph of the left hand o: ^ piuen:,iig£d nineteer. years, showing poly- 
 dactylism and syndactylism. The right hand was similarly affected. Episcopal Hospital. 
 
 Webbed Fingers Syndactylism) (Fig. 531) may be treated by several 
 forms of plastic operation. Didot's method (1S5C) is sufficiently indi- 
 cated by the accompanying figure (Figs. 532). There is great ten- 
 dency for the web to re-form, and it always is well to carry the inci- 
 sions far down between the heads of the metacarpal bones. For this 
 reason Agnew's operation ''Fig. 5.33) is preferable, as it provides a flap 
 of healthy skin over the v,-eb. 
 
 Congenital Contraction of a Finger may require some form of plastic 
 operation, after excision of dense bands of connective tissue. In the 
 case represented in Fig. 534. full extension became possible only when 
 the anterior ligament of the interphalangeal joint was divided. 
 
CONGENITA L DISLOCA TIONS 
 
 507 
 
 Congenital Dislocations. Congenital Dislocation of the Hip is 
 
 (lif most t'r('(niciil of these congenital luxations. Some authorities 
 believe that the displacement of the hones may not always date 
 
 Fig. .531.^ — Webbed fingers; age fourteen Fig. 532. — Didot's operation for webbed 
 years. Orthopsedio Hospital. fingers. 
 
 from fetal existence, but may be produced by uterine contractions 
 during l)irth (Allis, 1907), or after birth by injudicious attempts 
 to extend the baby's thighs; however, it is very generally agreed 
 
 Fig. .533. — Agnew's operation 
 for webbed fingers. 
 
 Fig. 534. — Congenital contracture of fifth finger; 
 age sixteen years. Episcopal Hospital. 
 
 that there is a congenital malformation of the acetabulum and of the 
 head of the femur or both, possibly due to malposition within the 
 uterus. The deformity is more common in female (85 per cent.) than 
 in male (15 per cent.) children, and more often unilateral (63 per 
 
508 
 
 ORTHOPEDIC SURGERY 
 
 cent.) than bilateral (30 per cent.). The dislocation is posterior in 
 the overwhelming majority of cases. The longer the dislocation 
 stays unreduced the more does the capsule contract around the acetab- 
 ulum, forming an hour-glass-shaped channel through which it may 
 become impossible to replace the head. The acetabulum, which is 
 shallower than normal, becomes more so as life advances unless the 
 femoral head is replaced in it and normal weight-bearing is restored. 
 
 Symptoms. — Frequently nothing abnormal a})out the child is noted 
 until walking is attempted, when a limp is visible in the unilateral 
 cases (Fig. 535), and a characteristic waddle in the double dislocations. 
 
 Fig. 535. — Congenital dislocation of left hip, in a boy of two years. Limp first noted 
 on attempts to walk at the age of fifteen months. Episcopal Hospital. 
 
 Tn the latter there also develops marked lordosis (Fig. 536), because 
 the centre of support is displaced posterior to the centre of gravity. If 
 the dislocation is not reduced, deformity and disability usually increase 
 with age; and in most cases adolescents and adults must lead a semi- 
 invalid existence. The diagnosis is made from the history, from the 
 symptoms noted above, and from the physical examination. This 
 shows moderate shortening of the extremity affected (Fig. 537) , eleva- 
 tion of the trochanter above Xelaton's line, and absence of the femoral 
 head from its socket. By alternately pulling and pushing on the fully 
 extended lower extremity, while the pelvis is fixed, the great trochan- 
 
CONGENITAL DISLOCA TIONS 
 
 509 
 
 ter will 1)0 foiiiui to slide up iuid down. When the two tliif^hs are 
 flexed to a rifi;ht an^lc, with the knees bent, and the child on its l)aek, 
 the thi<;h on the afl'ected side is found shorter. 'Jliere is diminished 
 abduction, especially when the thi^di is Hexed to a ri^dit angle. Flexion 
 and (extension are free and painless, facts which together with the 
 history readily serve to distinguish this aflection from traumatic dis- 
 location. In coxa vara the head of the hone is in the acetabulum; and 
 in coxalgia there is an acute arthritis, 
 or its resultant deformity. Confirma- 
 tion of the diagnosis of dislocation is ob- 
 tained by skiagraphy, w'hich usually 
 shows more or less anicvcrsion of the 
 head of the femur: that is, instead of 
 pointing inward toward the pelvis, the 
 neck of the fenuir lies more nearly in the 
 sagittal plane, the head pointing forward 
 even when the lower limb is not rotated 
 outward. 
 
 Treatment. — Reduction should be ac- 
 complished as soon as the diagnosis is 
 made. In very young children, reduc- 
 tion is not difficult to secure by the 
 usual methods for dislocation of the hip 
 (p. 408); but in all cases reduction is 
 very difficult to maintain owing to the 
 shallowness of the acetabulum, the de- 
 formation and anteversion of the head, 
 and the resiliency of the soft parts. 
 After the age of eight or nine years it 
 is ^'e^y difficult and sometimes impos- 
 sible to obtain reduction without open 
 operation, wdiich is called by the Ger- 
 mans the "bloody" as distinguished from 
 the "bloodless" method of reposition. 
 
 Paci, of Pisa (1888, 1894), was an early exponent of the bloodless 
 method, which he systematized, and Lorenz (1895) abandoned 
 his bloody method to take up a modification of Paci's operation, 
 which he has popularized all over the world. The child being 
 etherized and the pelvis fixed, the surgeon flexes and then 
 abducts the thigh until the adductor tendons become tense; these 
 are then ruptured subcutaneously by blows from the ulnar side of the 
 hand, or ])y violent massage. The limb is then forcibly hyperflexed, 
 with the knee extended, until it lies alongside the body, with the foot 
 beside the patient's head. When all resisting soft structures on the 
 anterior portion of the joint have been ruptured, reduction is 
 attempted: the trochanter is placed over a wedge-shaped block, and 
 by hyperabduction of the flexed thigh the surgeon pries the head of 
 the femur into its socket. The clenched fist may be \ised as a fulcrum 
 instead of Lorenz's wedge; but either method is liable to fracture the 
 
 Fig. 536. — Lordosis from double 
 congenital dislocation of hips, in a 
 girl of seven years. Orthopaedic 
 Hospital. 
 
510 
 
 ORTHOPEDIC SURGERY 
 
 cervix femoris (Tig. o39). According to Bade 0909), nerve injury, 
 resulting in paralysis, has occurred in 07 out of 2204 cases of blood- 
 less reposition; and many surgeons have produced one or more frac- 
 tures of the femur, myself included (in a patient over eight years of 
 age). A much safer and equally efficient method is that of G. G. 
 Davis (1907), in which the patient is placed prone on the table, and 
 the thigh is flexed until it lies alongside the chest, with the knee in the 
 axilla; this brings the head of the femur below but still posterior to the 
 acetabulum; then the adductors are gradually stretched by manual 
 pressure downward on the great trochanter (^Fig. 540) ; when these 
 
 Fig. 537. — Congenital di.slocation 
 of right hip. in a girl eight and 
 a half years old. (See Fia. 53S.) 
 Orthopaedic Hospital. 
 
 Flo. -JSS. — (.'o:. genital di>l'jeation 
 of right hip. Three and a half years 
 after reduction. Same patient as 
 Fig. 537. Orthopsedic Hospital. 
 
 structures have been stretched enough to allow the groin to come 
 in contact with the table, the head of the femur ma>' jump from the 
 posterior to the anterior plane of the pelvis with an audible and 
 palpable click. If not, the flexion of the thigh is slightly diminished 
 {i. e., it is drawn a little away from the chest) and its abduction is 
 slightly increased, by raising the knee a short distance from the table. 
 Pressure downward on the trochanter is continued until the head of 
 the femur can be felt by the finger in the groin. If reduction cannot 
 be secured at the first attempt without the use of unjustifiable force, 
 it is better to dress the limb in the fullest abduction possible and 
 
CONGEMTA L DISIJH A TIOXS 
 
 511 
 
 make another attcnij)! sc\cral weeks later il' iieeessary, after sub- 
 cutaneous tlivision of tlie adductor muscles, close to the pubis. 
 When reduction has been secured, tiiis fact may be determined 
 
 (1) l)y hearinj^ or fecHng the femoral head junij) into tlie acetabulum; 
 
 (2) by observinjf that the knee can no lonj^er be fully extended, since 
 the ascent of the femur from the posterior plane of the innominate 
 
 Fig. 539. — Fracture of neck of femur when hyper-abduction is attempted 
 according to Lorenz's method. 
 
 bone to the acetabulum has caused a relative shortening of the ham- 
 strings; (3) by palpating the head of the femur in its socket below 
 Poupart's ligament; (4) b}' reproducing the luxation and again redu- 
 cing it; and (5) by skiagraphy. Sometimes an "anterior transposition" 
 only is secured : in this the head, instead of jumping into the acetabu- 
 lum, passes above it to a position just below the anterior superior spine 
 
 Fig. 540. — G. G. Davis's method of reducing congenital dislocation of hijj. 
 Orthopaedic Hospital. 
 
 of the ilium; of course this is not so favorable a result as an "anatomical 
 reposition," but it is better than a persistence of the dislocation, since 
 it transfers the weight-bearing point to the centre of gravity. 
 
 After reduction the head of the femur is not at all stable in its ill- 
 formed socket, and the chief difficulty and tedium in the care of these 
 cases arises in the after-treatment, in efforts to prevent relapse. The 
 limb should be dressed in plaster of Paris in the most stable 'position; 
 
512 ORTHOPEDIC SURGERY 
 
 usually this is with the thigh flexed to a right angle and abducted 
 beyond the coronal plane; that is, so that the knee is in a plane 2^05- 
 terior to the symphysis pubis (Fig. 541). This, the "primary position," 
 
 Fig. 541. — Congenital dislocation of right hip; primary dressing. Photographed 
 two weeks after operation. Same patient as Pigs. 537, 538, and 543. Orthopaedics 
 Hospital. 
 
 Fig. 542. — Frog position after reduction of congenital dislocation of both hips. 
 Orthopaedic Hospital. 
 
CONGENITAL DISLOCATIONS 
 
 513 
 
 called also the "tVo^^ position" wlicn hotli liij)s arc coiKHTiicd (Fig. 
 542), must l)c iiiaintaiiicd tor from four to six months. During this 
 time the child nuist be encouraged to walk about, with sup])ort, as 
 weijiht-bearing favors the deepening of the acetabulum. At the end 
 of this time, unless rcluxation has occurred or is inuuincnt, the abduc- 
 tion and ilexion may be diminished gradually, and the thigh dressed 
 in a less awkward position (Fig. 543), in which locomotion is easier. 
 Sometimes greater stability is secured by dressing the limb with the 
 patella looking directly forward, without any external rotation of the 
 thigh. Innnobilization of the hij) nuist be coutiinied, except in very 
 young children, for from nine to eighteen months after the primary 
 reposition, and for a similar or longer period after any recurrence of 
 dislocation and secondary reposition. 
 After this time external su])i)ort may 
 be discontinued, and gentle passive 
 motion and massage may be prescribed. 
 The younger the child, the sooner, as 
 a rule, can external support be dis- 
 pensed with, and the sooner will func- 
 tion return. 
 
 If reluxation recurs persistently, and 
 in cases where bloodless reposition is 
 impossible, a resort to open operation 
 usually is proper. The best approach 
 is by an anterior incision, along the 
 inner border of the sartorius. HoflFa 
 (ISOO) used a posterior incision with 
 temporary resection of the great tro- 
 chanter, but later abandoned this 
 method. Lorenz (1892) used an in- 
 cision from the anterior superior iliac 
 spine to the great trochanter, passing 
 between the tensor vaginae femoris 
 and gluteus medius; I have used this 
 method with satisfaction. Ludloflf 
 (190(S) uses an internal incision, pass- 
 ing between the adductors and pecti- 
 
 neus. In all cases the capsule is widely opened, preserving the 
 Y-ligament; and the acetabulum is cleared out sufficiently to hold 
 the head of the femur. Structures preventing reduction should be 
 divided; but in adults, where utmost efforts sometimes fail to secure 
 reduction, it may be sufficient to form a new^ socket above the 
 acetabulum (G. G. Davis, 1908). A certain measure of relief will be 
 secured if the head of the femur becomes more firmly fixed, in any 
 position, than it was l)efore operation. 
 
 Congenital Dislocation of the Shoulder. — In many cases it is prob- 
 able that the displacement occurs during obstetrical delivery. The 
 dislocation nearly always is subspinous (Fig. 544); the attitude is 
 characteristic; and the diagnosis easy. Reduction rarely is possible 
 33 
 
 Fig. 543. — Congonital dislocation 
 of right hip in walkiup; cast. Same 
 patient as Figs. 537, 538, and 541. 
 Orthopsedic Hospital. 
 
514 
 
 ORTHOPEDIC SURGERY 
 
 Fig. 544. — Congenital dislocation of 
 the left shoulder. Age seven years. 
 Orthopcedic Hospital. 
 
 without open operation. This dis- 
 location not infrequently accom- 
 panies the condition designated 
 "brachial birth palsy," and accord- 
 ing to T. T. Thomas, the dislocation 
 is the essential lesion (p. 2S3). 
 
 Congenital Elevation of the Scapula, 
 Sprengel's Deformity (1891).— The 
 upper extremity develops as an 
 appendage of the cervical spine, 
 and if normal descent of the scap- 
 ula fails to occur, it remains in the 
 cervico-dorsal region, more or less 
 deformed, often being fixed to the 
 \'ertebral spines by a process of 
 bone or cartilage. The subject has 
 been studied recently by A. E. 
 Horwitz (1908), who analyzed 136 
 cases. In the patient under my own 
 care (Fig. 545), who also presented 
 
 Fig. .545. — ( 'ongcnital elevation of left 
 scapula in a boy of three years; before 
 operation. Orthopaedic Hospital. 
 
 Fig. 54(i. — ('ongcnital elevation of 
 left scapula, three months after opera- 
 tion. Orthopaedic Hospital. 
 
CONGENITAL T A LIVES 
 
 515 
 
 con^M'iiital scoliosis and al)S('nce of several rihs, marked iiiij)rovenient 
 resulted t'roin open section of the muscles attached to the xertehrai 
 border of the scapula, depression of the scapula, and re-attachment 
 of the rhomboids to the upper anjjle of the bone (Fig. 54()), 
 
 Congenital Dislocation of the Knee is quite rare, and usually is 
 anterior in direction, the leg being hyperextended on the thigh. The 
 patella may be absent. The use of splints or orthopedic api)aratus 
 usually secures a return to the normal position, with moderate range 
 of fl(>xion, before the age for AA'alking arrives. 
 
 Congenital Talipes. — The cause of congenital foot deformities is 
 unknown, though they often are attributed to malj)osition in the 
 uterus. The hands sometimes are the 
 seat of similar deformities {Cluh Hands). 
 The deformity may affect one or both 
 feet. There are several distinct types 
 of deformity, though usually more than 
 one is present. Talipes Equinus is 
 "pointed toe" deformity in w'hich the 
 front of the foot is depressed and the 
 heel elevated, the patient walking on 
 the toes, as a horse, whence the name. 
 In Talipes Calcaneus the heel is de- 
 pressed and the toes elevated. In 
 Talipes Varus the anterior part of the 
 foot is adducted, and the foot is inverted 
 (supinated); the inner border of the 
 sole is shortened and elcA'ated, and the 
 patient walks on the outer border. In 
 Talipes Valgus the anterior part of the 
 foot is abducted, the foot is everted 
 and pronated, the sole is flat, and the 
 inner border of the foot is convex. In 
 Talipes Cams or Arcuatus ("hollow 
 foot") the arch of the foot is high, and 
 the foot is shortened antero-posteri- 
 orly, without being either pronated or 
 supinated. 
 
 At birth there seldom is appreciable bony deformity, but contrac- 
 tures of tendons and ligaments as well as of the skin and subcutaneous 
 tissues are present. If the deformity is not overcome while the bones 
 are soft, these will become deformed, adapting their form to the 
 altered function required by weight-bearing and locomotion. 
 
 Equino-varus. — The most frequent combination of congenital 
 deformities is that of equimis and tarns, forming the ordinary "club- 
 foot" (Fig. 54S); there often is slight cams as well. The feet turn 
 in, the soles face each other, the tibial border of the sole is concave 
 and shortened, and the heel is elevated. There is no natural ten- 
 dency for the deformity to correct itself; on the contrary, if patients 
 
 Fig. 547. — Congenital talipes 
 equinus, with slight cavus deform- 
 ity in a boy of thirteen years. 
 Orthopaedic Hospital. 
 
51G 
 
 ORTHOPEDIC SURGERY 
 
 Fig. 548. — Congenital equino -varus (double), age 
 seven months. (See Fig. 549.) Orthopiedie Hospital. 
 
 are iie<i;lec'te(l and allowed to walk, the deformity constantly increases 
 until in extreme cases they may have to walk on the dorsum of the 
 foot (Fig. 549). The tibialis anticus and posticus are short, and keep 
 the foot inverted; the tendo Achillis raises the heel; the i)lantar fascia 
 
 is contracted and arches 
 the foot, and the flexors 
 of the toes aid in causing 
 cavus deformity. The cal- 
 caneum long remains small 
 and ill-formed, and the calf 
 muscles are poorly devel- 
 oped, because of disuse; 
 and the extensors of the 
 toes and the peronei, which 
 work at marked disadvan- 
 tage, are weak and totally 
 unable to overcome the 
 deformity. 
 
 Treatment. — In earliest infancy manual correction alone may suffice, 
 if it is applied intelligently and at least twice daily. Holding the 
 leg bones at the malleoli in one hand, the other hand forcibly abducts 
 the foot, so as to stretch the shortened tissues on the inner side of the 
 sole. This is repeated from ten to twenty times, morning and night. 
 When the aflduction can be over- 
 come, and the foot brought into a 
 straight line with the leg, but not 
 before, attempts are made to bring 
 the heel down by dorsi-flexing the 
 foot in the sagittal plane. By no 
 means should the tendon of Achilles 
 be divided so long as there remains 
 the slightest tendency to varus; 
 without the calcaneum as a fixed 
 point (made so by the attachment 
 of the Achilles tendon) it is impos- 
 sible to overcome by manipulation 
 the adduction of the foot. From the 
 age of a few weeks until the child 
 begins to stand, the foot should be 
 held in the best position obtainable 
 at each manipulation by being ban- 
 daged to a posterior right-angled 
 splint, or in plaster of Paris. If plas- 
 ter of Paris is used, the case should 
 
 be renewed every two or three weeks and the foot put up again in the 
 
 improved position secured by renewed manipulation. Sometimes it is 
 
 necessary to anesthetize the baby to apply manipulation effectively. 
 
 If this treatment is faithfully carried out there are very few cases 
 
 Fig. 549. — Inveterate varus. Same 
 imtient as Fig. 548, three years later. 
 Has received no treatment; walks on the 
 dorsum of his feet. Orthopaedic Hospital. 
 
CONGENITAL TALIPES 
 
 517 
 
 of cliil) foot in whicli the feet will not be in sufficiently ^ood position 
 for weight-hearing- when tlie age for walking arrives. At this stage 
 braces may be applied, to be worn night as well as day, but removed 
 daily for washing and manipulation; and these must be continued 
 until there is no further tendency to relapse. The main factors in such 
 apparatus are a strong laced shoe, open to the toe, so that the foot 
 can be inserted easily; an instep strap to hold the foot against the 
 sole, and keep the heel from rising; side irons to prevent inversion of 
 the foot; and an elastic strap from the outer side of the foot to the 
 outer side iron, to keep the ankle dorsi-flexed and the foot everted. 
 Apparatus is not designed to overcome deformity, but acts merely as 
 do splints in the case of fractured bones, to maintain proper position 
 after this has been secured })v other means. These braces (as all 
 
 h'lG. 5.30. — Double eciumo-vuriiii 
 (congenital). Age .seven years. Re- 
 lapsed case, from neglect of treatment. 
 Orthopiedic Hosijital. 
 
 Fig. 551. — Relapsed varus. Rear view 
 of patient in Fig. 550. (See Fig. 556.) 
 OrthopEedic Hospital. 
 
 other orthopedic apparatus) will require constant oversight and 
 adjustment, and this must not be shirked by the surgeon who under- 
 takes the treatment of such cases. Braces present the great advan- 
 tage over gypsum that they permit muscular action, and so favor 
 development of the hmb. Usually they should extend to mid-thigh, 
 for greater security; and where internal rotation of the foot is per- 
 sistent, it may be necessary to add a pelvic band, so as to ha^'e some 
 fixed point by which to evert the entire lower extremity. 
 
 In cases in which proper treatment has been neglected, and in 
 relapsed cases (Figs. 550 and 551), mere manipulation usually is 
 powerless to overcome the deformity. Here the patient must be 
 anesthetized, and more forcible stretching done, as indicated in the 
 accompanying illustrations (Figs. 552, 553, 554 and 555). The foot is 
 
518 
 
 ORTHOPEDIC SURGERY 
 
 Fig. 552. — Club-foot wedge in use, ovtrcominL: \ .uu-. Orthopaedic Hospital. 
 
 Fig. 554. — Use of G. G. Davis's lever to stretch tendo Achillis. Orthopsedic Hospital. 
 
CONGKN 1 TA L TA L 1 PES 
 
 519 
 
 dressed in over-corrected position in plaster of I'aris and the patient 
 stays in hed several days after the oj)erati()n, and for the first twenty- 
 
 ^rJ^^BIP^ 
 
 
 ^■^^^^^^^ - ..!«i^^^B 
 
 
 ^^^Lf^sea^sfaaaJkesmimima^r. - ■ 
 
 Fig. 555. — G. G. Davis's ^•aI■us niafliinc in use. ( )rth()ija'dic H(jspital. 
 
 four liours the foot is kept elevated to prevent edema. Walking in 
 the gypsum case is then allowed. If the stretching {redressement force) 
 
 is skilfully done, evil consequences 
 are very unusual, though rarely a 
 superficial slough may form o^•er the 
 dorsum of the foot. The plantar 
 fascia often is tense, and usually 
 should be divided; but tenotomy' of 
 the tendo Achillis or other tendons 
 seldom is advisable. Tenotomy usu- 
 ally is done by the subcutaneous 
 method (Stromeyer, 1831) : a punc- 
 ture is made by a sharp-pointed 
 tenotome (Fig. 557) just to one side 
 of the tense tendon and where it 
 is most accessible; a blunt-pointed 
 tenotome is then inserted beneath 
 the tendon, and while this is kept 
 taut, it is divided from within out- 
 
 FiG. 556. — Double ccjuino-varus 
 after use of instruments sliown in Figs. 
 552 to 554. Same patient as Figs. 550 
 and 551. Orthopaedic Hospital. 
 
 Fig. 557. 
 
 -Sharp and blunt-pointed 
 tenotomes. 
 
 ward by a gentle sawing motion; any oozing of blood is checked 
 by pressure and an aseptic dressing appliefl with the limb as much 
 
520 
 
 ORTHOPEDIC SURGERY 
 
 over-corrected in position as is possible; and this position is maintained 
 by a fixed dressing; for four to six weeks. Tlie tendo Achillis is divided 
 ai)()ut an inch above its insertion; the tibialis anticus below the annular 
 ligament; the tibialis posticus between the internal malleolus and its 
 
 Fig. 558. — Double congenital talipes valgus. Age t\v(j and a half years. 
 Orthopedic Hospital. 
 
 point of insertion; and the peroneal tendons behind and above the 
 external malleolus. 
 
 In cases in which bony deformity has developed, which cannot be 
 overcome by forcible manipulation as above indicated, it may be 
 
 necessarv to do some formal cut- 
 
 ting operation. Phelps 
 divided all the structures (skin, 
 muscles, tendons, ligaments) on 
 the contracted side, in the same 
 plane, until the astragalo-scaphoid 
 joint was widely opened, and 
 dressed the foot in over-corrected 
 position, packing the wound with 
 gauze. While this is efficient in 
 overcoming deformity at the time, 
 relapses are not unknown, and the 
 foot is stiff and functionally im- 
 paired at the best. Ogston (iS92), 
 ^lenciere of Uheims, and Barlow, 
 in the case of very young children, 
 have adopted a method called by 
 ^lenc'iere " modelage parevidemeiH;" 
 this consists in excavating all but 
 a shell of the calcis, astragalus and 
 cuboid, by means of a small curette, 
 and then forcibly correcting the deformity, a procedure which is 
 rendered easy by the temporary weakness produced in the bones. In 
 most cases of bony deformity in children or adults, the best method 
 
 Fig. 559. — Congenital clul>feet and 
 contracture of knee. Age three years. 
 Episcopal Hospital. 
 
PA RA L Y TIC DEFOIi.\ffTII'JS 
 
 521 
 
 of ()V(*r('()niiii<; tlio doformity is to do cuneiform tarsectomy, or wedj^e- 
 sliapcd ri'soctioii ol' the tarsus (\{. I)a\\-, lSSlj:iii this operation u 
 wod^e of l)one (regardless of tlie outlines of the individual bones), 
 witii its base on tiie dorsum and its apex on the sole, is removed from 
 across the tarsus; the portion excised hv'iu^ sufhciently lar<re to allow 
 over-correction of the deformity. Astragalectomy, which is preferred 
 by many surgeons, is more difHcult of execution, and leaves a less 
 shapel}' foot than does cuneiform tarsectomy. 
 
 Other forms of congenital talipes (Fig. ooS), as well as club-hand, 
 contracted knee (Fig. 'mI)), etc., are so rare that it seems unnecessary 
 to discuss them here, as the princi|)les of treatment are the same as 
 in equino-\arus. 
 
 PARALYTIC DEFORMITIES. 
 
 Acute Anterior Poliomyelitis. —Paralytic Talipes.— ]\Iost of the para- 
 lytic deformities which re(|uire orthopedic treatment are the result 
 of "infantile paralysis," though 
 cases occasionally are encountered 
 the eflFect of cerebrospinal menin- 
 gitis, diphtheria, or other rarer 
 infections. The vast majority of 
 cases of infantile palsy involve one 
 or both lower extremities, espe- 
 cially the feet. The extent of the 
 paralysis is very variable; it may 
 affect only one muscle group, or a 
 single muscle ; or it mav affect both 
 lower extremities in their entirety, 
 forcing the child to walk on his 
 hands, using the feet merely as 
 props (Fig. 5()0), or occasionally 
 inducing a quadrupedal gait; or 
 the trunk also may be paralyzed, 
 rendering the child helpless. In- 
 fantile palsy affecting one side of 
 the back, is an occasional cause 
 of scoliosis (Fig. 579). In some 
 cases there is only slight tendency 
 to contractures of the unparalyzed 
 
 muscles, the paralyzed part remaining entirely flaccid ; while in others, 
 contractures are an early and prominent symptom. In nearly every 
 case deformity eventually develops. 
 
 When it has been ascertained that paralysis exists, it is important 
 to institute mechanical treatment at once, to prevent, so far as 
 possible, the development of deformity, and to encourage return 
 of function. Even the weight of the bed-clothes on the toes may be 
 injurious, predisposing to equinus deformity. The foot should be 
 
 Fig. 560. — Infantile palsy of both lower 
 extremities. Position assumed in walk- 
 ing on hands. Age four years. Ortho- 
 psedic Hospital. 
 
522 
 
 ORTHOPEDIC SURGERY 
 
 and use 
 
 supported at a right angle with the leg, and the knee and hip should 
 be kept fully extended, by suitable splints or apparatus. Meanwhile, 
 massage and electric treatment (galvanism) should be employed, 
 of the limb encouraged, provided that proper posture is 
 maintained. Usually after a month or 
 two the extent of the paralysis will be 
 fairly well defined, but under conserva- 
 tive measures, further improvement 
 may occur for two or three years. If 
 proper treatment (orthopedic support, 
 massage, electricity) has been insti- 
 tuted promptly, and faithfully pur- 
 sued, usually there will be no further 
 improvement after the lapse of this 
 time. But in all cases where such 
 treatment has not been employed, the 
 surgeon should delay resort to opera- 
 tive methods until trial has been made 
 of mechanical support, massage, etc., 
 for at least two years. 
 
 If deformity develops from neglect 
 of, or in spite of. proper support by 
 apparatus, various forms of paralytic 
 talipes may be present. These are dis- 
 tinguished from the 
 congenital talipes by 
 their being acquired, 
 the second or third year of, life, as the 
 result of an acute, even if slight, febrile attack, after which the child 
 began to limp; by their flaccid character, some muscles being notice- 
 ably paralyzed, while others by overaction cause persistent deviation 
 of the foot; by reactions of degeneration in the paralyzed muscles 
 when their electrical con- 
 tractility is investigated 
 (these never exist in con- 
 genital talipes); and by 
 marked atrophy of the 
 parah'zed limb. 
 
 The most frequent de- 
 formity is equino-var us, due 
 to paralysis of the peroneal 
 muscles, often associated 
 with loss of power in the 
 extensor longus digitorum 
 and extensor longus hallucis; the tibialis anticus and posticus act 
 as strong inverters of the foot, and the unopposed flexors and 
 calf muscles maintain foot-drop (Fig. 561), producing a potential 
 equinus which if long uncorrected may become a fixed deformity 
 
 Fig. 561. — Paralytic foot-drop, in 
 a girl of fourteen years. OrthopEedic 
 Hospital. 
 
 deformities of 
 the history of 
 usually during 
 
 Fig. .562. — Paralytic equinus, age twenty years, 
 deformity growing steadily worse since childhood. 
 Orthopaedic Hospital. 
 
PARALYTIC DEFORMITIES 
 
 523 
 
 (Fi^'. oC)^). Ill otlier cases there is no marked coiitraeture of the 
 acti\e muscles, but owing to the paralysis, tlie foot easily turns into 
 a position of extreme deformity (Fig. oOlJ), rendering locomotion 
 almost impossible without apparatus. P(irali/iir Cdlcdiiciis (l''ig. .')(').")) 
 
 Fici. 5G.3. — Paralytic varus before 
 operation. Age fifteen jears; dura- 
 tion eight years. (See Fig. 564.) 
 Orthopaedic Hospital. 
 
 Fig. 56-1. — Patient shown in Fig. 503, after 
 transplantation of tibialis anticus to base 
 of fifth metatarsal bone. Orthopaedic Hos- 
 pital. 
 
 Fig. 565.— Paralytic calcaneus, showing attitude assumed in walking. Aged twelve 
 years; duration eight years. Left foot assumed similar attitude as soon as any attempt 
 at motion was made, but patient could not balance himself long enough with both feet 
 in action for a photograph to be taken. (See also Fig 566.) Orthopaedic Hospital. 
 
524 
 
 ORTHOPEDIC SURGERY 
 
 is clue to paralysis of the calf muscles; the unopposed extensors cause 
 the toes to fly into the air at each step; sometimes there is dislocation 
 
 of the peroneal tendons anterior to the 
 external malleolus. Calcaneus deformity 
 usually is combined with marked cavus 
 (P^ig. 566), though this may exist alone, 
 from contracture of the plantar fascia 
 and extensors of the toes, when the short 
 foot muscles (interossei and lumbricals) 
 have been paralyzed (Fig. 571). Para- 
 lytic Valgus (Fig. 569) is much more 
 common than a similar congenital de- 
 formity; usually the two tibial muscles 
 are paralyzed, and sometimes the flexors 
 of the toes as well. Usually the peronei 
 are cbntracted. 
 
 When it has been ascertained that no 
 further improvement is to be expected 
 without operation, the aim of the sur- 
 geon should be to devise some means 
 Pi,; 56(i.— Paralytic calcaneus, ''>' ^vhich apparatus may be discarded. 
 showing secondary cavus, when \Yhenever there are a sufficient number 
 
 toes were forcibly flexed. Same c i 1^1 1 !> j.\ -^ • 
 
 patient as Fig. 565. ot healthy muscies tor the purpose, it is 
 
 Fig. 567. — Paralytic calcaneus after transplantation of the peronei and tibialis 
 posticus into the caicaneum, showing power of raising the heel. (See Figs. 565. 566, and 
 568.) Orthopaedic Hospital. 
 
PARMA TIC DEFORMITIES 525 
 
 possible, \)\ cliaii^iiig tlie points of insertion of one or more, so to dis- 
 tribute the muscular power wliieh remains as to secure to the patient 
 a well balanced foot. This o])erati(m is known as Tendon Transplanta- 
 tion. It seldom isadvisable to employ it before the age of six years, since 
 before this age it is very difficult to be certain which muscles are 
 functionally active, because this is a point ascertained much more 
 accurately by clinical observation than by investigation of the elec- 
 trical reactions. IJefore tendon transplantation is attempted, it is 
 important to overcome all deformity, and this may require repeated 
 manipulation under an anesthetic, red ressement force (as in congenital 
 talipes, p. 518), or even tenotomies; only when the foot can be held 
 
 Fig. 568. — Paralytic calcaneus two months after tendon transplantation. 
 (See Figs. 565, 566, and 567.) Orthopaedic Hospital. 
 
 in the over-corrected position by the pressure of one finger, will it 
 be safe to resort to operation. The best method of tendon trans- 
 plantation is the periosteal insertion of Lange (1898); this may be 
 succinctly described by a concrete example, namely, the transplan- 
 tation of the tibialis anticus to the base of the fifth metatarsal 
 bone, for the relief of ^'arus due to paralysis of the peroneal muscles. 
 Under Esmarch anemia the tibialis anticus is divided at its insertion, 
 and is drawn out of its sheath through a second incision made over 
 its course above the annular ligament; a subcutaneous channel is 
 then burrowed from above the annular ligament to the tuberosity 
 of the fifth metatarsal bone, and through a third incision at the 
 
526 
 
 ORTHOPEDIC SURGERY 
 
 latter })()iiit tlie tendon of the tibialis anticus is drawn down, and under 
 the utmost possihk- tension is sutured to the periosteum by several 
 
 Fig. 569. — Paralytic valgus, age seven 
 years; treated by tendon transplantation. 
 (See Fig. 570.) Orthopsedie Hospital. 
 
 Fig. 570. — Patient .shown in Fig. 569. 
 After transplantation of peroneus brevis 
 and tertius to insertion of tibialis anticus. 
 
 mattress sutures of strong chromic catgut. The foot is immobilized 
 in over-corrected position (valgus), in gypsum, for eight weeks; func- 
 tion is then gradually resumed. 
 
 ^ 1 The tibialis antictis being now 
 
 ^^^^^ -^/tT >v^ inserted on the outer side of the 
 
 ^^^Er " 7 J ^^"^^ ^^^^ ^*^"^ ^^ ^" everter, largely 
 
 ^^^1 A fl replacing the paralyzed peronei, 
 
 ^^^H I ^^A 1 and rendering the further use of 
 
 ^^^H ^^^^^B I apparatus 
 
 ^^^H ^H^^H I In similar manner, for other de- 
 
 ^^^H ^^^^^^B I formities, ^'arious other tendons 
 
 ^^^H ^^^^^^H fl may be transplanted, as will oc- 
 ^^^H ^^^^^^H ■ to the mind of any ingenious 
 
 ^^^V ^^^^^^B H surgeon. For paralytic valgus it is 
 ^^^ ^^^^^V V best to transplant the extensor 
 
 B^ ^^^^^^^^m fl longus hallucis to the insertion of 
 ^^j^^^^^^^^^^r fl the tibialis anticus; when the exten- 
 
 ^^^^^^^^^^^^m ^M longus hallucis paralyzed 
 
 ^^^^^^^^^^^^■■■i^HH ferred to the insertion of the tibi- 
 
 FiG. 571. — Paralytic cavus, age alis anticus (Figs. 5G9 and 570); or 
 
 eleven years showing over-action of if the extenSOr longUS digitorum is 
 the extensor longus hallucis. Ortho- .. j, t , i i p .i j.m • i- 
 
 pffidic Hospital. active, the (h.sinl end ot the tibiaUs 
 
I'A UAL YTK ■ DKI'OUMrjJI'JS 
 
 527 
 
 aiiticus (<livi(le<l al)(>\e the annular li^anicnt) may be sutured to this 
 healthy tendon. For paralytic cavus, the extensor lon^'us lialiucis, 
 which is usually the deforming factor (Fig. 571), may be attached to 
 the head of the first metatarsal. For paralytic calcaneus the peronei 
 and tibialis posticus may be traiisi)lanted into the insertion of the 
 tcndo Achillis (Figs. 5(')r) to 5()S). For paralysis of the quadriceps 
 femoris one or more of the hamstrings may be transplanted into the 
 patella; and for paralysis of the internal rotators of the thigh, the 
 tensor fascijie femoris may be transplanted into the great trochanter 
 (G. G. Davis. 1011). 
 
 Fic 
 
 572. — Paralj-tic flail-foot, age eighteen j-ears; duration fourteen years. 
 (See Fig. 573.) Orthopaedic Hospital. 
 
 In many cases it is possible by shortening paralyzed tendons to 
 enable them to act as ligaments in maintaining better position, or 
 when slight power remains, to enable them to use it to better advan- 
 tage. If a healthy tendon is too short to be available for purposes 
 of transplantation, silk strands may be attached to its end in an imbri- 
 cated manner, and the tendon thus lengthened the required amount. 
 
 Nerve Anastomosis has been employed in some cases of paralytic 
 deformities of the feet, but not with much success. It should be 
 reserved for those cases in which the entire distribution of one nerve 
 is })aralyzed, but in which the entire flistril)ution of a neighboring 
 nerve is intact. I employed it in one case in which the entire distri- 
 bution of the anterior tibial nerve was paralyzed, but in which that 
 of the musculo-cutaneous was unaffected, anastomosing the peripheral 
 
528 ORTHOPEDIC SURGERY 
 
 end of the anterior tibial into the musculo-cutaneous; but no power 
 was re«;aine(l. 
 
 Arthrodesis. — When so many muscles are paralyzed that none are 
 available for transplantation, it is possible to convert a "dangle-foot" 
 with flail-joints (Fig. 572) into a firm and useful support by pro- 
 ducing an artificial ankylosis (Fig. 573). This operation, known as 
 arthrodesis (Fig. 574), should not be undertaken before the age of 
 nine years at least, since the bones of younger patients are still too 
 cartilaginous for firm union to follow a joint resection. For "foot- 
 drop," arthrodesis of the ankle-joint is done: through a small trans- 
 verse incision over the front of the joint, displacing the tendons, the 
 articulating surfaces of the astragalus, tibia, and fibula are removed.^ 
 
 Fig. 573. — Result of arthrodesis of ankle, and subastragalar joints for paralytic 
 flail-foot (Fig. 572). (See Fig. 574.) Orthopedic Hospital. 
 
 For lateral mobility, subastragalar arthrodesis is done; in eight cases 
 I have found a single external incision, above the peroneal tendons, 
 sufficient to remove the articulating surfaces of astragalus and calca- 
 neum, as well as those of astragalus and scaphoid (Fig. 165). The 
 wounds are closed without drainage, and the foot is fixed in gypsum 
 for eight weeks, when walking may be resumed; but a light brace 
 should be worn for a few months more. 
 
 1 To secure closer apposition, Goldthwait (1908) advises osteotomy of the fibula 
 just above the malleolus, with inward displacement of this process against the 
 astragalus. 
 
I'ARALvric 1)1<:f()I{Mitu<:s .)2<) 
 
 In somr cases hoforr the ])atioiit is old ciioukIi to have arthrodesis 
 (hme, a Ihiil-joint may he rcMidered more or less firm l)y the insertion 
 thron^h the hones of sIvdikj .sill: .siituirs, to act <i.s lif/ainntt.s' (Lan^'e, 
 
 19l)o). 
 
 Fig. 574.- 
 
 -Rcsult of arthrodesis of ankle and subastragalar joints. 
 572 and 573.) Orthopa?dic Hospital. 
 
 (See Figs. 
 
 Infantile Paralysis of the Up- 
 per Extremity (Fig. 575), much 
 rarer than paralytic affections 
 of the lower limbs, is treated 
 on the same general princi- 
 ples. Transplantation of mus- 
 cles has been done chiefly at 
 the shoulder where a portion 
 of the trapezius or of the pec- 
 toral is major has been used 
 to supplement the deltoid. 
 Nerve anastomosis has given 
 no better results than in the 
 leg. 
 
 34 
 
 Fig. 575. — Infantile palsy of right arm. 
 Children's Hospital. 
 
530 
 
 ORTHOPEDIC SURGERY 
 
 Cerebral Palsies. — These result from cortical or meningeal hemor- 
 rhages, or from congenital defects, such as porencephalon. Spas- 
 ticity is their main characteristic, and by this factor it usually is 
 possible to distinguish them from infantile paralysis, which is 
 flaccid. In children they usually occur from injury at birth, and 
 there often is mental impairment (p. 576), In adults they may 
 follow cranial injuries, apoplexy, etc. The paralysis is hemiplegic, 
 paraplegic, diplegic, or monoplegic, according to the site of the cere- 
 bral lesion. The hemiplegic form is most frequent, the paraplegic 
 next, while the monoplegic or diplegic types are quite rare. The 
 flexor muscles are stronger than the extensors, and the deformity is 
 
 quite characteristic: the arm is adducted, 
 the elbow flexed, the forearm pronated, the 
 wrist flexed and the hand clasped tight; the 
 hip is flexed and adducted, the knee slightly 
 flexed, and the foot in the equino-varus 
 position, there being a tendency to walk 
 on the toes (Fig. 576). By gradual steady 
 pressure it usually is possible to correct 
 these contractures, but as soon as pressure 
 is released they recur, the patient having 
 very little if any voluntary control of the 
 aft'ected limbs. In the course of time the 
 deformity becomes permanent, unless mal- 
 ])osition is prevented by orthopedic means. 
 Treatment. — The treatment consists in 
 the use of massage and manipulation to 
 prevent the contractures from becoming 
 permanent. Malposition should be pre- 
 vented by splints or braces. Tenotomy 
 will improve position temporarily, but 
 relapses are common. A longer inter- 
 mission before relapse, and better prospects 
 of permanent functional improvement are 
 oft'ered by intra-perineural ncuroiomy after 
 the method of Xutt (1909): the nerves 
 supplying the spastic muscles are di^'ided and at once reunited 
 by suture; temporary paralysis of all the spastic muscles follows, 
 injurious peripheral impulses are abolished; and return of power to 
 the muscles paralyzed by the neurotomy is so slow that the weaker 
 antagonistic muscles are given a chance to recuperate. P^orster 
 (1908) has practised intradural division of the sensory nerve roots 
 {Rhizotomy) supplying the affected extremity, but the operation 
 is dangerous and the results very uncertain. Schwab and 
 Allison (1909) have used intraneural alcohol injections. In most 
 cases the disability is lasting, and no form of treatment is "of 
 much avail. 
 
 Fig. 576. — Infantile spastic 
 paraplegia, age three years. 
 Attitude in attempting to 
 walk. Orthopaedic Hospital. 
 
LATERAL CL'RVATl'HE OF THE SPINE oM 
 
 LATERAL CURVATURE OF THE SPINE. 
 
 Lateral Curvature of the Spine, or Scoliosis, is an aH'cction of cliild- 
 liood. It is coinoiiii'iit to <listiiij,niisli hotwceii functional or })osiiir(d 
 lateral curvature and true orf/auic or structural .scoliosis. Tlie former 
 is due sinij)ly to malposition, and tiiere is a general (sinj^ie) cnrAature 
 of the spinal eolunm, usually eonvex to the left. Hound shoulders 
 often eoexist. If neglected, these children may develop true structural 
 scoliosis, as the hones still are soft and their shape is readily altered 
 by long continued uneciual pressure. The diagnosis of postural 
 lateral curvature is easily made by dropping a plumb-line from the 
 vertebra prominens, and noting the deviation of the sj)inous processes. 
 The child may be brought for examination on account of stooping, 
 round shoulders, or general relaxation of the joints. Proper gymnas- 
 tics, attention to hygiene, manner of supporting the clothing, etc., 
 usually effect a cure in from one to two years. The clothing should 
 not be supported by the points of the shoulders, but as far as possible 
 from the ])elvis, or from the slope of the neck; any ordinary gym- 
 nastic and calisthenic exercises are efficient; over-study and tire should 
 be avoided, and an active out-of-door life encouraged. 
 
 In organic or structural scoliosis there is, in addition to lateral devia- 
 tion of the spinal column (Fig. 577), also rotation of the bodies of the 
 vertebrae, the transverse processes of the vertebrae rotating backward 
 on the convexity of the curve, and forward on its concavity. This 
 rotation is best appreciated by having the patient bend the body 
 horizontally from the hips (Fig. 578). 
 
 Scoliosis may be due to a number of causes: (1) It may develop, 
 as already mentioned, as a sequel of jwstural lateral curvature; this 
 probably is the most frequent cause. Sometimes it is convenient to 
 recognize as a predisposing cause, in cases beginning this way, a 
 rachitic or other dystrophic softening of the bones, to account for the 
 rapidity with which structural changes occur in the spinal column. 
 (2) Congenital anomalies of the spine (studied at length by jNIouchet 
 and Rouget in 1910); there may be a supernumerary wedge-shaped 
 vertebra; or a portion of one or more vertebrae, with or without their 
 attached ribs, may be absent. The deformity in these cases is recog- 
 nized in early infancy, anfl the bony lesion usually can be detected 
 in a skiagraph. (3) Infantile paralysis or other muscular lesion, 
 allowing unopposed contraction of the muscles on the unaffected side 
 (Fig. 579), is a rather unusual cause. (4) Empyema, causing collapse 
 of the thorax on the afi'ected side, is a frequent cause (Fig. 762). (5) 
 Torticollis, and other deformities of neighboring parts, such as anky- 
 losis of the hip in bad position, causing tilting of the pelvis, should also 
 be remembered as occasional causes of this deformity. 
 
 In most cases, as already mentioned, the deformity arises from 
 faulty attitudes in sitting, standing, sleeping, etc. It develops most 
 frequently between six and ten years of age, and occurs in girls in over 
 75 per cent, of cases. The child carries heavy books or a heavy baby 
 
532 
 
 ORTHOPEDIC SURGERY 
 
 habitually on one arm; sits at school or at home at a desk or table 
 disproportionately high, requiring habitual undue elevation of the 
 right shoulder; one leg may be a trifle shorter than the other, or the 
 patient may sit on a cushion higher on one side than on the other, 
 inducing obliquity of the pelvis — in short, from causes, which often 
 cannot be defined, the patient is brought to the surgeon (unfortunately 
 seldom until the deformity has existed for some years) complaining 
 of asymmetry, with projection of one shoulder and one hip, usually 
 the right. Such patients should be examined with the back bare from 
 
 Fig. 577. — Scoliosis, in a girl of sixteen 
 years; left shoulder droops, right thorax 
 (convex curve) is prominent. (See Fig. 
 578.) Orthopsedic Hospital. 
 
 Fig. 578. — Patient in Fig. 577, stoop- 
 ing to show posterior rotation at the side 
 of the convexity of the curve. Ortho- 
 paedic Hospital. 
 
 neck to pelvis, and without shoes on their feet. Even if no asym- 
 metry is evident at a glance, it is extremely likely that after standing 
 a few minutes the slouching attitude will come on, and reveal the 
 deformity. In the immense majority of cases there is a cur^•e convex 
 to the right in the thoracic region, which compensates a curve convex 
 to the left in the luml)ar region, the latter being regarded as the 
 primary curve. (If the case is one of postural scoliosis only, there 
 seldom is more than one curve, which usually is convex to the left; 
 placing a lift under the left foot usually causes the curve to flisappear.) 
 The line of the waist is more cut in on the left side, a distinct fold 
 
LATERAL CURVATl'RE OF Till-: SI'IXE 
 
 533 
 
 often existing:; (Fig. 577); and when the patient st()()[)s forward at the 
 hips the right thorax becomes prominent, the left h)in projects, and 
 the riglit loin falls away (Fig. 57.S). In extreme eases the anterior 
 surface of the thorax is deformed also, the left lower rihs hecoming 
 very prominent, and the apex of the right lung being markedly com- 
 pressed; sometimes the liver is proptosed, and the heart displaced to 
 tFie left. Valvular incomi)etency is frequent in cases of great 
 deformity. Besides the deformity, 
 the patient complains of tiring easily, 
 of weakness, or of marked disability. 
 
 Diagnosis.- In cases of very slight 
 degree it is didicult sometimes to be 
 certain that the affection is scoliosis 
 and not incipient tuberculosis of the 
 spine. In the latter condition there 
 may be lateral deviation of the spine 
 without any kyphosis; l)ut the lateral 
 deviation is more abrupt than tlic 
 gentle curve of scoliosis (Fig. 639) ; 
 there is painful rigidity of the spine as 
 detected by flexion, hyperextension, 
 and lateral bending; there usually is 
 tenderness localized to the seat of 
 disease; there may be constant, slight, 
 evening rise of temperature; and the 
 tuberculin test probably will be posi- 
 tive. A skiagraph may reveal a 
 tuberculous lesion; but in cases of 
 scoliosis, except those easily recog- 
 nized as such clinically, will show no 
 bony change. If the slightest doubt as 
 to the nature of the trouble persists, 
 treatment for Pott's disease (p. 609) 
 should be instituted until its absence 
 is proved. 
 
 Treatment. — The mildest grades of 
 rotatory scoliosis may be overcome 
 by correction of habitual malposi- 
 tion and special gymnastic exercises 
 
 under the supervision of a competent orthopedic surgeon. The 
 patient should sleep on a hard, flat bed, without a pillow, and 
 either supine or prone; she should spend at least one hour each 
 day lying flat on her back on a hard level couch or on the floor; and 
 should give up habits of writing, reading, sewing, etc., which require 
 a cramped posture. Where pain or disability is marked, recumbent 
 treatment, with head and foot extension, as for Pott's disease should 
 be instituted. The exercises prescribed for scoliosis cannot be 
 detailed here ; they form almost a sub-specialty in orthopedic practice, 
 
 Fig. 579. — Iiicipii'nt scoliosis, fol- 
 lowing infantile palsy one year ago. 
 Age four years. Left side paralyzed. 
 Orthopffidic Hospital. 
 
534 
 
 ORTHOPEDIC SURGERY 
 
 and are of a highly technical nature. They should l)e taken daily 
 (at least three times weekly) for from one to three hours for a period 
 of nine months up to one or two years. It is folly to expect per- 
 manent improvement sooner. In most cases, certainly in those in 
 which noticeable rotation is present, the patient should be provided 
 with some form of spinal support; for all severe grades of deformity 
 this is more important than gymnastics, as it is futile to expect to 
 correct bony deformity l)y muscular exercise. As H. Bigg (1905), 
 L()\'ett and Seever (1911), and other recent writers, ])oint out, the 
 
 Fig. 5MI.-— Plaster nf I'aris jacket, 
 applied ueeordiiig to Abbott's method 
 for the treatment of scoliosis (curve 
 convex to right in thoracic region). 
 Large window cut over the hollow re- 
 gion; the left shoulder held high and 
 forward; the right shoulder forced 
 down and backward ; the pelvis rotated 
 forward toward the right. Orthopaedic 
 Hospital. 
 
 Fig. 581. — G. G. Davis's brace for scoliosis. 
 Orthopaedic Hosi)ital. 
 
 deformity should be treated on the 
 same principles that guide us in 
 treatment of other bony deformities, 
 such as bow-legs and club feet. 
 The most efficient corrective apparatus is a gypsum jacket, applied 
 according to the method of Abbott (1912) with the patient lying 
 supine on a canvas sling, attached at each end to a special frame. 
 This sling is cut on the bias at one end, so that when one side of the 
 sling is pulled taut the other is relaxed. The taut side of the sling 
 is placed under the prominent side of the thorax, and the patient's 
 head and thighs are thoroughly flexed. Then bands are attached to 
 the sides of the frame to assist over-correction of the deformity, and 
 the plaster of Paris is applied and moulded carefully to the body, 
 
STATIC iJISOliDEh'S OF THE lA'MBAU Sl'lSE AM) I'KLVIS o'.i') 
 
 wliicli lias hei'ii i)a(l(lo<l witli saddler's felt until a])])r<).\i!nately syrii- 
 inetrical in t'orni. When the plaster lias set, larj^e windows are cut over 
 the eomi)resse(i portions of the thorax (usually over the left scajjula 
 and lower ribs j)osteriorly, and the right mammary region anteriorly), 
 and the pads over these eompressed portions are remove<l, while 
 increasing ])ressure is brought to hear on the ])rominent portions of 
 the thorax hy inserting, at intervals of a few (hiys, broad felt pads 
 between the thorax and jacket (Fig. 580). The same jacket may be 
 worn for a jH'riod of from two to three months. A new jacket then 
 is ai)plied for a month or six seeks longer; and this treatment is con- 
 tinued until ovcr-corirrtioti of the deformity has been obtained. This 
 form of treatment is the most efficient yet de\ised. When oxer- 
 correction has been secured and maintained for a few weeks, sym- 
 metry is restored by gymnastics. Treatment by gypsum jackets as 
 formerly ai)plied, had to be continued indefinitely, as relapses were 
 frequent and very prompt after apparently complete cures. In 
 Abbott's method, however, the reduction of deformity is reasonably 
 rapid and if over-correction can be secured, appears to be lasting. In 
 less severe cases removable jackets or spinal l)races (Fig. 581) may be 
 used, constructed to act on the same principles as al)ove described; 
 but they are less efficient than irremovable gypsum jackets even 
 though they permit coincident use of gymnastics. 
 
 STATIC DISORDERS OF THE LUMBAR SPINE AND PELVIS. 
 
 These were studied in 1901 by Goldthwait, and are frequent causes 
 of neurasthenia, backache, and general disability, especially in women. 
 After childbirth, or during convalescence from some wasting disease, 
 or simply from malnutrition, overwork, etc., the tone of the pelvic 
 and lumbar muscles is lowered, and undue strain is thrown on the 
 ligaments. Similar symptoms may occur after prolonged anesthesia, 
 during which the patient has lain on her back without support to the 
 lumbar spine; some cases of "lumbago" are due to similar conditions; 
 and most patients wuth what has long been called "neurotic spine" 
 have some static disturbance with ligamentous strain as the basis of 
 their trouble. 
 
 The most frequent condition is a loss of the normal lumbar lordosis; 
 occasionally, however, somewhat similar symptoms follow increase 
 of the lordosis, caused by wearing very high-heeled shoes, by anky- 
 losis of the hip in a flexed position, etc. Flatness of the back often 
 is associated with weak or pronated feet (p. 547), and is relieved by 
 treatment of the foot condition. 
 
 The normal lumbar lordosis disappears at first merely when the 
 patient is supine; later it is absent also in the erect posture. The 
 sacro-iliac joints and symphysis pubis may become relaxed, and pain 
 may be referred down the sciatic nerves; while at each step the patient 
 may feel discomfort and may obtain relief onl>- by lying prone, or 
 supine with the lumbar spine supported by a pillow. One sacro-iliac 
 
536 
 
 ORTHOPEDIC SURGERY 
 
 joint frequently is more relaxed than the other. By placing one hand 
 over the joint while the other palpates the symphysis pul^is, it usually 
 is possible to detect abnormal mobility as the patient stands first 
 on one foot then on the other. Or with the patient lying prone, 
 the sacro-iliac joints may be made to move by hyperextending the 
 thighs. 
 
 Treatment. — The treatment in mild cases consists in massage of 
 the lumbar muscles, with gymnastic exercises. In severe cases it may 
 be necessary to put the patient to bed with weight extension to the 
 lower extremities; later some form of spinal and pelvic support must 
 be provided. For sacro-iliac relaxation the application of a firm 
 
 Fiu. 582. — iSacio-iliae sprain, with re- 
 laxation (left side). For eight months 
 pain in left hip, back, and down sciatic. 
 Diagnosed Pott's disease, elsewhere. Or- 
 thopsedic Hospital. 
 
 Fig. 583. — Belt for sacro-iliac relaxation. 
 Orthoptedic Hospital. 
 
 pelvic belt between trochanters and iliac crests often is all that is 
 required (Fig. 583). Where the lumbar spine also is involved, it will 
 be necessary to support this also: this may be accomplished by the 
 application of a light gypsum jacket, with the patient lying prone on 
 a hammock, as in Pott's disease (p. 611), or by some form of ortho- 
 pedic corset which will maintain hyperextension of the lumbar spine. 
 Spondylolisthesis is the term given to subluxation of the last lumbar 
 vertebra forward on the sacrum; occasionally the fourth lumbar 
 vertebra is displaced forward on the fifth. The affection is com- 
 monest in young adult females, but occurs also in growing girls and 
 in youths and young men. There is a depression above the sacrum, 
 
DEFORMITIES OF THE HEAD AND KECK 
 
 bXi 
 
 over the hist hinihar vertebra, and sometimes a promhienee ean be 
 felt above tlie sacral eminence by a finger in the rectum or vagina. 
 The symptoms and treatment are nuich the same as for static 
 strains of the lumbar spine, of which, indeed, spondylolisthesis may 
 be considered the terminal stage. 
 
 DEFORMITIES OF THE HEAD AND NECK 
 
 Torticollis, Caput Obstipum, or Wry-neck, sometimes is (lue to 
 injury at birth, rupturing some of the fibres of the sternomastoid or 
 other cervical muscle. It is uncertain whether the cases of hematoma 
 of the ster)w-mastoid muscle sometimes seen in infants are a result of 
 the rupture of the nuiscle because it was congenitally short, or are 
 themselves the cause of wry-neck by causing subsequent cicatricial 
 contraction of the muscle. Often 
 the deformity is not noticed until 
 the child, is several months old, 
 and then it is difficult to be 
 certain whether the affection is 
 congenital or acquired. As a 
 rule, the congenital affection is 
 painless, while the accjuired form 
 has a more or less acute onset. 
 Torticollis may be symptomatic 
 of certain other diseases, as 
 astigmatism, or cervical Pott's 
 disease (p. 603), fracture-dislo- 
 cation of the cervical, spine, cer- 
 vical rib, cervical adenitis (Fig. 
 584), "rheumatic stiff neck," 
 toothache, ear-ache, tonsillitis, 
 or other affection which may 
 irritate the spinal accessory or 
 upper cervical nerves, causing 
 
 spasticity of the muscles concerned in the production of the deform- 
 ity. These are especially the sternomastoid, the trapezius, and the 
 scalenus anticus, especially the sterno-mastoid. 
 
 Symptoms. — The head is rotated to the opposite side, the chin point- 
 ing to the unaffected shoulder, while the ear approaches the shoulder 
 of the affected side (Fig. 585). If the deformity continues long uncor- 
 rected, it may lead to facial asymmetry, scoliosis, or other secondary 
 deformities which cannot be remedied. 
 
 Treatment. — The surgeon should first ascertain that the deformity 
 is not of the symptomatic variety; if it is, removal or proper treat- 
 ment of the cause of irritation usually will cause the wry-neck to 
 disappear. If no cause other than a shortening of the muscles can be 
 found, attempts may be made by massage, gymnastics, or apparatus 
 to overcome the deformitv. If these fail, as in most cases they do, 
 
 Fig. 584. — Torticollis from cervical adenitis. 
 Children's Hospital. 
 
538 
 
 ORTHOPEDIC SURGERY 
 
 I'k;. ')bo. — ( 'Diiiit'iiital tui'tK 
 quired scoliosis. Note asymmetry 
 Children's Hospital. 
 
 with ae- 
 of face. 
 
 the surgeon may resort to division of the contracted structures. In 
 cases of short duration this usually is quite efficient, })ut in many 
 
 pntients the most that can be 
 expected is a lessening of de- 
 formity. It is better to divide 
 all resisting structures by open 
 section than to attem})t a sub- 
 cutaneous operation ; very 
 dense cicatricial bands, which 
 may exist in the cervical 
 fascia, should be excised, and 
 the muscles may be divided 
 trans\ersely and left unsu- 
 tured, or some form of 
 muscle lengthening, analogous 
 to the lengthening of ten- 
 dons may be employed. The 
 head is then dressed in an 
 over-corrected position, main- 
 tained by a gypsum case . 
 (Fig. 58()), or orthopedic ap- 
 paratus. 
 Spasmodic Torticollis, a form of Tic Convulsij, is an affection of 
 obscure origin, consisting essentially in sudden tonic involuntary, 
 and usually painful contraction of the neck muscles, momentarily 
 turning the head into a wry- 
 neck position. The extent of 
 the spasm, and the number 
 of muscles involved, varies 
 greatly. The disease usually 
 begins insidiously, in young 
 adult life, but progresses with- 
 out intermission until almost 
 the entire body may be in- 
 volved; any effort to move or 
 speak, and especially any ex- 
 citement, brings on a spasm, 
 and the patient may curl up 
 in a knot, as it were, on the 
 side affected, being abso- 
 lutely helpless and unable to 
 straighten himself out. ]Many 
 surgical measures have been 
 tried, but none have had 
 permanent good effect; but 
 as the same can be said for 
 
 medical measures, the temporary relief which follows operation should 
 not be despised. Division of the nerves supplying the cervical muscles 
 
 Fig. 586. — Gypsum dressing after operation 
 for left-sided congenital torticollis. Age nine- 
 teen years. Orthopjedic Hospital. 
 
DEFORM! TIES OF THE HEM) AND NECK 
 
 530 
 
 most nflVcti'd is tlu' oix^ratioii usually (lone, ('s[)('<ially dixision of the 
 spinal acc('ssor\ or upper (rr\ical nerves (Keen, hSUl j. 
 
 Cervical Ribs. On one or both sides of the neck a rudimentary 
 ril) may he t'ornied, usually attaelied to the seventh eervieal vertebra, 
 but occasionally to the sixth. The all'ection is said to be bilateral in 
 7") per cent, of eases, and occurs in females three times as often as in 
 males. If the rib is very short, no symptoms may be produced, l)ut 
 usuall.\' it is long enough to reach to the subclavian artery, which 
 passes o\er the rib, and may be compressed, causing .symptoms of 
 munbness, tingling, etc., in the extremity affected. Pressure on the 
 iiraciiial plexus, cervical sympathetic or j)ncumogastric nerves may 
 
 Fig. 587. — Cervical rib (left) ; age eighteen years. Numbness, tingling, etc., for 
 four months. (Dr. W. J. Taylor's case.) Orthopaedic Hospital. 
 
 also occur. Usually no trouble is experienced until adult life (Fig. 
 587). In most cases the rib is palpable in the neck; and the abnormal 
 position of the artery, as well as changes in the radial pulse, may 
 simulate aneurysm. Rest for a few weeks, with elevation of the arm, 
 usually causes subsidence of acute symptoms. When these recur, 
 and are disabling, excision of the abnormal rib should be done. The 
 operation may be very difficult, from the altered relations of blood- 
 vessels, ner^•es, and muscles, and from the proximity of the pleura. 
 Complete recovery is the rule, even if temporary paralysis occurs 
 from careless handling of the nerves. 
 
540 ORTHOPEDIC SURGERY 
 
 ACQUIRED DEFORMITIES OF THE UPPER EXTREMITY. 
 
 Cubitus Valgus, or increase of the normal ''carrying angle" of 
 the upper extremity, sometimes follows rachitis, but most often is 
 the result of a fracture of the lower end of the humerus. It is less 
 frequent and less disabling than cubitus varus, which almost always 
 is due to fracture, especially supracondylar fractures of the humerus. 
 Either deformity may be treated by supracondylar osteotomy of the 
 humerus. Some surgeons prefer to dress the arm in full extension 
 after the operation: if this is done, for valgus deformity the forearm 
 should be kept in supination, which relaxes the muscles passing from 
 the external supracondylar ridge; while for varus the forearm is 
 dressed in full pronation, making these muscles tense, and, there- 
 fore, restoring the carrying angle. If the elbow is dressed in 
 hyperflexion, as in a recent supracondylar fracture, the precautions 
 mentioned at page 340 against varus and valgus deformities should 
 be observed. 
 
 Ischemic Contracture (Stromeyer, 1S3S; Volkmann, 18()9) is due to 
 muscle and nerve degenerations following ischemia caused by pressure 
 of splints or bandages applied for a fracture of the elbow or forearm. 
 ^^ery rarely it has followed injury in which no splint or dressing of 
 any kind had been used. It has been reported as affecting the lower 
 extremity also. Bardenheuer (1911) in his recent elaborate study 
 of the question, concluded that the degenerative changes were due to 
 venous stasis, the muscle cells being poisoned by metabolic products 
 in the blood, and that the primary cause is not an anemia of the parts. 
 Nerve involvement in cases of ischemic contracture has been empha- 
 sized by J. J. Thomas (1909). The hand swells and becomes cyanosed, 
 and the parts are extremely painful; but the constriction is not suffi- 
 cient to cause gangrene. After a few days the pain ceases, and swelling 
 may subside. The damage is done within a few hours, and cannot be 
 repaired merely by removal of the splints; it is far better to be sure 
 in the first place that the dressing used does not interfere with the 
 circulation. Usually the condition develops in what appears an 
 insidious manner only because the surgeon is not on the lookout for 
 it; if interference with the circulation persists for several hours there 
 is already nerve and muscle degeneration, and if the surgeon was suf- 
 ficiently attentive he would discover it at the next dressing, and not 
 be surprised when subsequent deformity develops. 
 
 The deformity is quite characteristic (Fig. 588), resembling that of 
 ulnar paralysis; nor is this resemblance surprising since the ulnar 
 nerve often is involved (Fig. 589). But even if the symptoms of 
 neuritis are present, and they are not in all cases, there are also 
 symptoms of fibrous degeneration of the muscles on the flexor side 
 of the forearm. The joints are not affected, motion being limited 
 merely by muscular contracture: thus, when the wrist is fully flexed, 
 extension of the fingers becomes possible; but efforts to straighten 
 the wTist at once cause flexion of the fingers. Frequently there are 
 
ACQUIRED DKFORMlTll'JS OF THE I'l'l'Eli EXTREMITY .') 1 1 
 
 prossiire sores in tlio skin, and tlie resultinji; cicatrices aid in fixing 
 nuiscles, tendons, and niTves, in one almost inextricable mass of 
 adhesions. 
 
 Treatment. — \ ery little can be done imtil the ulcers have healed, 
 except to prevent further deformity. Xo remedial treatment should 
 be undertaken until acute symptoms ha\e subsided. Then trial may 
 be made of massage and passi\e motion; but usually very slif^ht if 
 any improvement is secured. R. Jones (1908) ai)plies a malleable 
 
 Fic. 58b. — I )cf(ii'iiiit \- fiill(iwinj£ \'()lkiiKiiiii's ischcinic contraftiirc and paralysis 
 of ulnar nei\e after frat-turc of elbow. Orthoi ledie Hosijital. 
 
 metal splint to each finger up to the carpal joints, first with the wrist 
 in full flexion, a position which usually permits nearly full extension 
 of the fingers; the wrist flexion is gradually diminished and the finger 
 extension progressively increased by changing the angle of the finger 
 splints; and in the course of several months the contracted tissues 
 may be sufficiently relaxed to permit fair function. In most cases, 
 however, especially in those complicated by nerve changes, operation 
 
 Fig. 589. — Ulnar paralysis and Volkmann's ischemic contracture after fracture 
 at the elbow. Episcopal Hospital. 
 
 is required. This consists in a free dissection of the muscles, tendons, 
 and nerves; in muscle and tendon lengthening (Anderson, 1889; 
 Littlewood and Page, 1898), and in preventing, so far as possible, 
 formation of new adhesions, by interposing flaps of fascia or pieces 
 of Cargile membrane^ between the various structures. Some brilliant 
 
 1 This is thin gold-beaters' skin, made from the peritoneum of an ox, first used 
 by an Arkansas physician named Cargile, and introduced to professional notice 
 in 1902 by R. T. Morris. 
 
542 ORTHOPEDIC SURGERY 
 
 results have been secured by these methods (Dudgeon, 1902; G. G. 
 Davis, 190K), but in many cases the operation has to be rei)eated a 
 number of times Binet (1910) has studied 141 cases of Volkmann's 
 contracture, and prefers to treat them by resection of the radius and 
 uhia, shortening the forearm until the tendons become relaxed suffi- 
 ciently to straighten the fingers (Colzi, 1892; Henle, 1896; P>oelich, 
 1909); but while good results have followed this method it is better 
 in every case to make sure that the nerves are freed from adhesions. 
 Spontaneous Subluxation of the Wrist or Manus Valga (Made- 
 lung's Disease, 1878). — The symptoms of this affection usually are 
 manifested about the age of puberty; it affects particularly females; 
 involves both wrists in about 50 per cent, of cases; is characterized 
 by dorsal projection of the lower ends of the ulnse, by slight radial 
 deviation of the hand, and in its more advanced stages by subluxa- 
 tion of the wrist forward at the radiocarpal joint (Fig. 590). Espe- 
 cially characteristic in radiograms is the widening of the interosseous 
 space, due to incur^'ation of the lower end of the radius, the normal 
 flexor concavity of which becomes much exaggerated. The hand thus 
 is carried forward with the articular surface of the radius, while the 
 ulna, which is not displaced forward, appears to be unduly prominent. 
 Siegrist (1908) collected 62 cases, only 10 of which were in males. 
 
 Fig. 590. — Madeluiig'.s disease; male, aged twenty-four years. Began about 
 eight years of age. Episcopal Hospital. 
 
 The aft'ection has been attributed by some to adolescent rachitis; 
 others are s'atisfied to describe it as an obscure form of osteitis affecting 
 the radius. In the Tast few years there has been a tendency to regard 
 it as a congenital deformity, to which attention is first directed at 
 an age when local over-exertion and constitutional malnutrition exert 
 their influence. In addition to the deformity there often is discom- 
 fort from pain or ache, and some disability from loss of extension and 
 circumduction at the wrist. Usually these are relieved In' si)linting, 
 or orthopedic apparatus, with constitutional treatment. In severe 
 cases osteotomy of the radius may be done to overcome deformity. 
 
 Contraction of the Palmar Fascia (Dupuytren's Contraction, 1832). 
 — This afl'ection occurs in adults past middle life, jjarticularly men, 
 and in some cases seems to be caused by slight recurring trauma from 
 the handles of tools, canes, etc. The patients often are gouty. In 
 about half the cases both hands are aft'ected, usually the right before 
 
ACQl'llil-^T) nKFOlUUTIE^ OF THE LOWER EXTREMITY :yV.\ 
 
 tlie left. TIio fascia is the seat of clironic infiaminatory cluui^es,' 
 with seeoudary contraction; it l)ec()mes densely adherent to the skin; 
 and the resnltinj:; deformity may totally disable the patient. The 
 tlmnil) and index fin|,a'r are the last to succnmh. 
 
 Fig. 591. — Dupuytrcn's contracture of the palmar fascia; earlj- stage. Age 
 • sixty-six years. Episcopal Hospital. 
 
 Temporary relief may be secured by tenotomy of the tense fascial 
 bands, introducing the tenotome between the skin and fascia and cut- 
 ting downward (Adams, 1879) ; the fingers should be dressed on a splint 
 in full extension for three weeks, and this splint should be worn at 
 night for three weeks longer. But recurrence of the deformity is usual. 
 Excision of the contracted bands was introduced by Kocher (1SS7), 
 and Keen (1906) reflected a skin flap, including the adherent fascia, 
 which was then dissected off the skin before this was replaced. The 
 fascia is so densely adherent that some sloughing is liable to occur. 
 Lexer and others have excised skin and fascia in one piece, and filled 
 the gap by a flap of skin transplanted from elsewhere. 
 
 Trigger Finger. — Trigger finger is a condition in which there is some 
 obstacle to vohmtary flexion or extension of the finger, which flies 
 "shut" or "open" when passively moved past the position where 
 it catches. The usual obstacle is a fusiform thickening of one of the 
 flexor tendons, and the hitch occurs where the deep tendon perforates 
 the superficial. If rest on a splint for some weeks, followed by massage, 
 proves inefTectual in relieving the condition, the tendon sheath may 
 be opened and the thickening of the tendon excised. Cotton (1911) 
 refers to 160 cases, in about 40 of which operation was done. 
 
 ACQUIRED DEFORMITIES OF THE LOWER EXTREMITY. 
 
 Coxa Vara. — Normally the neck of the femur forms an angle of 
 about 135 degrees with the shaft; when this angle is notably decreased 
 
 1 These are classed by the Lyons surgeons as a form of inflammatory tubercu- 
 losis. 
 
544 
 
 onrnoPEDic surgery 
 
 (115 degrees or less) coxa vara is said to exist. The deformity con- 
 sists in elevation of the great trochanter and a relative depression 
 of the femoral head, which, however, retains its position within the 
 
 Fig. 51)2. — Coxa vara, the result of injury during infauc.w 
 Episcopal Hospital. 
 
 re SIX years. 
 
 Fig. 593.— Skiagraph of double coxa vara (rachitic). Note rachitic pelvis- 
 acetabula pressed together. Orthopi3edic Hospital. 
 
ACQUlUEl) DEI'OHMITIES OF THE LOW Eli EXTREMITY 54o 
 
 uectabiilimi. (^oxa \ aru may result from trauma, especially ej)i[)liyseal 
 separation of tiie head or fracture of the (;ervix in children (Fig. ;')92); 
 from rachitic softening of tlie bones, when the deformity usually 
 is bilateral (Fig. r)9.S) ; or from no well very defined causes, chiefly in 
 a(h)Iescents. (See Rottenstein and Ilou/.el," 1<)I(); Calve, lOlO.) 
 
 Symptoms. Tiie symi)tonis are those of the underlying or preceding 
 condition; slight limp, limitation of abduction, because the trochanter 
 strikes the pelvis; marked prominence of the trochanter when the 
 thigh is flexed (Fig. 594); increased range of adduction, especially 
 when the thigh is flexed; elevation of the trochanter above Nelaton's 
 
 595. — Whitman's vvcclfio-shiiped oste- 
 otoniv i)f tlic femur for coxa vara. 
 
 Fig. 594. — Coxa vara from fracture 
 of cervix fenioris as infant. Note 
 prominence of great trochanter when 
 thigh is flexed. Episcopal Hospital. 
 
 Fit;. 596. — Whitman's operation for coxa 
 vara. Consolidation has occurred in the 
 abducted position. 
 
 line; and, in cases due to trauma, usually external rotation of the 
 lower extremity. There is moderate shortening, but seldom much 
 pain, relief being sought for the limp and deformity. 
 
 Treatment. — In many cases no treatment is required; in some, the 
 addition of a lift to the heel brings relief by overcoming shortening. 
 In cases with great deformity a cuneiform osteotomy of the femur 
 may be done, as advised by Whitman (1901), removing a w^edge 
 with its apex at the lesser trochanter; or simple linear osteotomy 
 may suffice. The thigh is dressed in extreme abduction, and when 
 consolidation is complete, adduction will restore approximately the 
 normal relations of neck and shaft (Figs. 595 and 590). In recent cases 
 of impacted fracture of the head or neck in children or adolescents, 
 35 
 
546 
 
 ORTHOPEDIC SURGERY 
 
 the deformity may be overeome by forcible abduction under an 
 anesthetic. 
 
 Coxa Valga (Fig. 597) is a much rarer conditi(jn, in which the neck 
 of the femur makes with the shaft an angle of more than 135 degrees. 
 The trochanter is less i)rominent than normally, abduction is increased 
 and adduction diminished. There usually is outward rotation of 
 the lower extremity. The deformity may be congenital and usually 
 is observed in limbs which never have borne any weight. P^fforts 
 may be made to increase the adduction by manipulation under an 
 anesthetic. 
 
 Fig. 597. — Coxa valga, apparently congenital, in a girl of twelv'e years. Angle 
 between neck and shaft is 165 degrees on the right; on the left (normal) it is 130 
 degrees. Episcopal Hospital. 
 
 Snapping Hip (die schnellende Hiifteja Ilanchea Ressort). This affec- 
 tion has been the subject recently of an elaborate study by L. Heully 
 (1911), who has collected 57 cases. He proposes the term " ressaut 
 fascio-ghiteal ," as explaining what he believes to be the pathology of 
 the condition which has been recognized since 1859, though dispute 
 as to its nature has always existed. Perrin, who reported the first 
 case, believed it to be a form of voluntary luxat on of the hip; 
 but the study of Heully confirms the opinion of Morel-Lavallee, 
 
ACQUIRED DEI'VRMITIKS OF THE LOWER EXTREMITY 547 
 
 Clmssaijjiiao, and others, that it is duo to sudden slippinj^ of the fascia 
 hita (altered by injury or ('on<cenitally deformed) oxer tlie surface 
 of tlie fi;reat troclianter. The j)lienonienon occurs esj)ecially (hirinji; 
 Hexion and internal rotation of the thi^h, but in some cases slij^ht 
 movements of the pelvis on the lower extremity are sufficient to 
 ])roduce it. In traumatic cases the lesion is sey)aration of the up])er 
 l)art of the tendon of the gluteus maximus from its insertion in the 
 linea aspera, and the snap occurs involuntarily and is painful; while 
 in conp;enital cases it is not painful and usually is under voluntary 
 control, possibly being due to abnormally low insertion of the gluteus 
 tendon in the linea aspera (Ileully). The defect may be repaired 
 by suturing the tendon to the periosteum of the great trochanter 
 and a])()neur()sis of the vastus externus. 
 
 Anterior Metatarsalgia. — T. G. Morton in 1876 described a condition 
 which was b^'lie^■e(l by him to be due to pinching of a nerve between 
 the heads of the fourth and fifth metatarsal bones ("^Morton's toe"). 
 A sudden unendurable cramp in the anterior metatarsus occurs while 
 the patient is walking, and he is forced to remove the shoe at once, 
 rub and manipulate the foot, and flex and extend the toes, until the 
 l)ain passes. This series of events may be repeated a number of 
 times, but except in the most aggravated cases the attacks never 
 come on except when walking, and with a shoe on the foot. More 
 recent observations, especially by Goldthwait and Whitman, have 
 shown that weakness in the transverse arch of the foot is an important 
 factor, and may cause various minor symptoms before metatarsalgia 
 develops. Callosities may form on the sole over the heads of the 
 metatarsals, especially the second and third; and pain may be caused 
 by lateral compression by a shoe which would be comfortable if the 
 normal convexity of the arch was maintained. Relief usually may 
 be obtained by wearing broader shoes, or b.y applying a small longi- 
 tudinal pad beneath the sole to support the centre of the transverse 
 arch, or a support may be worn in the shoe (beneath the insole) just 
 back of the heads of the metatarsals, thus relieving them from strain; 
 such an application is known as an anterior heel. The patient should 
 actively exercise the toes in flexion, and may benefit from massage. 
 IVIorton excised the head and neck of the aft'ected metatarsal. 
 
 Flat-foot (Pes Planvs). — This very frequent aftection is an evidence 
 of weakness in the foot. In a foot that is merely weak, however, 
 the antero-posterior arch may still be preserved, but a tendency 
 to pronation exists: when weight is put on the foot the internal 
 malleolus descends and rotates backward, causing a relative outward 
 displacement of the anterior part of the foot; the patient walks with 
 the toes well turned out, and to bring the two feet parallel it may be 
 necessary to rotate both entire lower extremities inward, so that the 
 patellae look toward each other rather than anteriorly. In truly flat 
 feet the arch is depressed, and in aggravated cases the scaphoid may 
 rest on the floor (Fig. 598). The affection is common at all ages, and 
 may be very disabling. In adolescents painful flat-foot often is an 
 
548 
 
 ORTHOPEDIC SURGERY 
 
 early evidence of tuberculosis of the tarsus, and this diagnosis always 
 should be carefully considered. In young children the foot remains 
 perfectly flexible, but if the condition persists for years unrelieved, 
 great rigidity may develop; and in adults more or less rigidity is the 
 rule. In cases where rigidity is absent much may be done by proper 
 exercises, even without mechanical support. The patient should 
 rise on to the toes of both feet simultaneously, from ten to twenty 
 times, morning and night; he should then attempt to supinate his 
 feet the same number of times by flexing his toes and contracting 
 the tibialis anticus and posticus muscles; and flexion exercises of the 
 toes with the feet oft' the ground also should be prescribed. Walking 
 on the toes, and on the outer side of the soles is another valuable 
 exercise. In most cases, however, it is desirable to support the arch 
 in walking: for this purpose the first thing is to secure a pair of strong 
 
 Fig. 598.— Flat feet, 
 years. (See Fig. 599.) 
 pital. 
 
 a a boy of eight 
 Orthopsedic Hos- 
 
 FiG. 599. — Flat feet foot-prints. 
 Same patient as Fig. 598. Ortho- 
 pasdic Hospital. 
 
 shoes, made on a straight or nearly straight last, with broad toes, 
 low heels and a wide shank; the shoes should be "high" shoes, laced. 
 Many sole plates are sold in the stores for the purpose, but as they 
 scarcely ever fit the foot to which they are applied, it rarely is proper 
 to use them. If a sole plate is to be used it should be made for the 
 individual patient, moulded on a cast of this foot taken in the resting 
 position. An easier and as efficient method, I believe, is to have a 
 shoemaker insert a steel strip in the shank of the shoe, and then to 
 build up the arch, to any height desired, by properly cut felt pads 
 placed beneath the inner sole. The height of this pad may be increased 
 or decreased at will. In very rigid feet, benefit is derived from massage, 
 passive movements, and baking. Sometimes " Mobilisierung" under 
 an anesthetic, with tenotomy of the tendon of Achilles or of the pero- 
 neal tendons, may be necessary; after such an operation the foot 
 
ACQUIRED DEFORMITIES OF THE LOWER EXTREMITY 549 
 
 is dressed in plaster of Paris in the varus i^osition for several weeks, 
 when proper ai)paratns may he appHech 
 
 Hammer Toe. Hanuner toe (Digitus iikiIIcn.s) is a dcforniity of 
 extension at the nietatarso-piiahingeal joint and flexion at tiie 
 proximal interphalangeal joint (Fig. 600). It is commonest in the 
 second toe, which, being the longest, suffers most from short and 
 narrow shoes. The condition usually })egins in childhood. A corn 
 forms over the prominent i)halangeal joint, and the end of the toe 
 liecomes club-shaped. If massage, application of adhesive i)laster 
 strapping, etc., do not relieve symptoms, tenotomy of tlie contracted 
 tendons (extensor and flexor) may be done; and in relapsed cases, the 
 toe may be anii)utate(l. 
 
 Fig. 600. — Hammer toe in a man of Fig. 601. — Hallux valgus, with a bunion 
 
 twenty-six; duration since childhood. over the head of the first metatarsal bone. 
 Episcopal Hospital. Age sixty-nine years. Orthopaedic Hospital. 
 
 Hallux Valgus. — Hallux valgus is a deformity in which the great 
 toe is abducted, often lying on the top of the other toes. This results 
 in marked prominence of the first metatarso-phalangeal joint; and 
 over this a bursa is formed by friction of the shoe (Fig. 601). In some 
 cases, the primary cause of the deformity is adduction of the first 
 metatarsal bone, due to the presence of a congenital anomaly, a bone 
 known as the intermetatarseum (J. K. Young, 1910); but I have 
 seen the intermetatarseum present without hallux valgus, and in 
 most cases no such bone exists, the deformity being caused by ill- 
 fitting shoes. If proper shoes, which do not abduct the toes, do not 
 secure relief, excision of the projecting head of the first metatarsal 
 may be done, C. H. Mayo (1908) preserves the bursa and inserts 
 it between the bones. 
 
 Painful Heel. — Painful heel may be due to a variety of causes. 
 Trauma may cause rupture of some fibres of the tendo Achillis, or 
 produce inflammation in the retrocalcaneal bursa (Achillobursitis), 
 
550 
 
 ORTHOPEDIC SURGERY 
 
 or in a bursa sometimes present between the Achilles tendon and 
 the skin; or it may cause strain on the attachment of the plantar 
 fascia, as is common in flat feet. Subsequently, exostoses may develop 
 at these points of strain. Infection^-, especially gonococcic, and 
 some forms of sub-pyemic or cryptogenous infection (Fig. G02) may 
 cause exostoses to form on the calcaneum or other tarsal bones; or 
 similar changes may be an evidence of hyperfrophic arthritis (p. 456). 
 
 Fig. 602. — Exostoses of calcaneum at attachments of plantar fascia and tendo Achillis, 
 in a patient aged forty-four years. Duration of s>-mptoms, over two months. Also 
 has incipient hypertrophic arthritis of hip. Orthopaedic Hospital. 
 
 Treatment. — The treatment consists in care of the underlying 
 condition (sprain, flat-foot, gonorrhea, etc.); local rest by proper 
 orthopedic shoes, etc.; and, in cases which resist conservative 
 measures, in excision of the exostoses. 
 
niAPTKR XVII. 
 SnUiKKV OF THE IIKAD. 
 
 SURGICAL AFFECTIONS OF THE SCALP. 
 
 Birth Injuries. — Durinij; parturition that portion of the scalp 
 whic'li protrudes into the birth canal may become edematous from 
 pressure on surrounding parts; this condition, which is known as 
 caput smrcdaneum, may be recognized by the history of prolonged 
 or difficult lal)or, by tlie facts that it is present at birth, that the 
 att'ectetl area pits on pressure and presents no signs of inflammation; 
 while it may be distinguished from cephalhematoma (see below) by 
 the fact that the swelling is not limited to the outline of one bone. 
 The swelling disappears in a few hours or days, and usually no treat- 
 ment is necessary. Cephalhe- 
 matoma is an extravasation of 
 blood beneath the pericra- 
 nium; it is encountered in 
 about one labor out of two 
 hundred. Usually the right 
 parietal is the bone affected, 
 and it is probable that in 
 many cases the bone itself is 
 directly injured, either bent 
 or broken (p. 564). As the 
 pericranium is attached at 
 the sutures, the hemorrhage 
 never passes the limits of the 
 bone affected; generally the 
 condition is not noticed for a 
 day or two after birth, and 
 at this time the blood at the 
 periphery may have become 
 
 clotted or organized, so that the scalp presents an indurated ring with 
 a softened or fluctuating centre. Occasionally thin plates of sub- 
 periosteal bone develop, and the bone crackles on palpation. In 
 most cases no treatment is required, but if no evidence of absorption 
 is seen after two weeks the fluid may be evacuated by puncture; 
 pressure should then be applied to prevent re-accumulation. Should 
 infection of the hematoma occur, from the deep skin cocci or through 
 the blood stream, it should be drained (Fig. 603). 
 
 Contusions. — Contusions of the scalp are frequent at all ages. If 
 the head is examined immediately after the injury the impress of the 
 vulnerating body may be detected; but swelling occurs very quickly, 
 
 Fig. 603. — -Suppurating cephalhematonia in 
 an infant of five weeks. Incised. Death in 
 four days. Children's Hospital. 
 
552 
 
 SURGERY OF THE HEAD 
 
 and usually the only signs are those of edema, and possibly hematoma. 
 The blood usually is extravasated in the subcutaneous tissues, super- 
 ficial to the aponeurosis of the occipito-frontalis. It may be difficult 
 to distinguish such cases, after the lapse of a few hours, from depressed 
 fractures of the skull as the contusion presents a soft depressed centre, 
 surrounded by an indurated area due to inflammatory reaction and 
 commencing organization; but firm pressure in the centre detects 
 solid bone at the same level as the surrounding cranial surfaces, and 
 there is no irregular outline to the depressed area, such as is commonly 
 present in fracture; moreover, the elevated margin moves \\ith the 
 
 scalp upon the bone beneath. In cases 
 of doubt the scalp should be incised and 
 the skull inspected. A hematoma beneath 
 the occipito-frontalis is widely diffused, 
 and may be of great size. In most cases 
 hematomas of the scalp subside under 
 pressure by bandages, application of cold, 
 and rest in bed; if no diminution in size 
 is evident after ten days, or if infection 
 occurs, the hematoma should be incised, 
 and pressure applied, when the cavity will 
 heal by granulation. 
 
 Wounds. — Wounds of the scalp may 
 result from blunt force, as well as from 
 cutting instruments, as the scalp is very 
 readily split on the underlying bone. 
 Bleeding is free, as the bloodvessels are 
 unable to contract and retract, being 
 enmeshed in the firm fibrous processes 
 which bind the skin to the aponeurosis. 
 This also renders it difficult to catch the 
 bleeding points in hemostats, or to apply 
 ligatures; and the surgeon often must de- 
 pend on sutures to arrest the bleeding. 
 Temporary control of hemorrhage is easily 
 secured by pressure on the margins of the wound ; and during an oper- 
 ation hemostasis sometimes may be secured by applying an Esmarch 
 band or other form of elastic tourniquet around the crown of the 
 head. Wounds w^hich divide the occipito-frontalis aponeurosis trans- 
 versely gape much more than longitudinal wounds; and when the 
 loose subaponeurotic areolar tissue is opened there is much greater 
 danger of infection arising, especially if the wound is closed without 
 drainage (Fig. 604). Owing to the great vascularity of the parts 
 large portions of the scalp may be avulsed and yet retain their vitality 
 when properly cleansed and sutured in place. When the skull has 
 been denuded of its pericranium over large areas, some caries is 
 ver}' apt to occur, but if the soft parts are promptly replaced no 
 such result need be anticipated unless infection is present. 
 
 Fig. 604. — Lacerated wound of 
 the scalp, with subaponeurotic 
 cellulitis; the result of sealing 
 the wound with a cotton and 
 collodion dressing. Forty-eight 
 hours after injury the cellular 
 infiltrate had gravitated into the 
 temporal region where it was 
 arrested by the attachment of 
 the temporal fascia to the zj-- 
 goma. Episcopal Hospital. 
 
SURGICAL AFFECTIONS OF THE SKULL 
 
 553 
 
 In all scalp wounds a lar«;(* surroundiiijj; area should he shaved, 
 all t'()rei>,ni hodies reuio\ed from the wound, and this should he cleaned 
 with antiseptics. Silkworm ^\\t sutures 
 should he used, and if there is any risk of 
 a hematoma forming, or if the subapon- 
 eurotic sj)ace has been opened, the wound 
 sliould be ilrained for a few days. 
 
 Tumors. — Tumors of the scalp apart 
 from sebaceous cysts{ Fig. 223, p. 2()5) are 
 not very frequent. In infancy dermoid 
 ci/sts (Fig. 22(), p. 2()()) sometimes are 
 seen; these usually grow in the region of 
 the embryonal clefts, occurring in or near 
 the orbit, at the glabella, or over one of 
 the fontanelles; usually they are more or 
 less immobile, deep-seated, and are not 
 attached to the epiderm, being thus easily 
 distinguished from ordinary wens. If not 
 removed in infancy, the underlying bone 
 may be absorbed from pressure, and the growth may become adherent 
 to the dura mater, making its removal more difficult. Papillomatous 
 growths of the scalp should be eradicated by cauterization, or excised, 
 as they are prone to undergo epitheliomatous change. Epithelioma 
 often develops in scars from burns, syphilitic ulcers, etc. Sarcoma 
 may arise in the scalp or the cranial bones, and the latter are rapidly 
 invaded by tumors which at first were superficial (Fig. fiOo) . Usually 
 no operation is of any use. 
 
 ¥ir.. tjUo. — Sarcoma of scalp. 
 Death a few months after 
 photograph was made. (Dr. 
 W. L. Rodman's case.) Pres- 
 byterian Hospital. 
 
 SURGICAL AFFECTIONS OF THE SKULL 
 
 Congenital Malformations. — Cephalocele. — Occasionally at or soon 
 after birth a fluctuating tumor of the head is found wdiich 
 evidently protrudes through the skull and is composed of cranial 
 contents. The growth occurs oftenest in the region of the posterior 
 fontanelle (occipital cephalocele), though it ma}' also protrude at the 
 root of the nose (sincipital cephalocele), or very rarely at the anterior 
 fontanelle or through one of the cranial sutures. The tumor usually 
 is wholly or partly reducible by pressure, which if excessive may 
 cause symptoms of cerebral compression (p. 573) ; and it becomes more 
 prominent and tense when the child cries. It frequently is possible 
 to detect the defect in the cranium through which the protrusion 
 occurs. If the protrusion is composed solely of the meninges, with 
 subarachnoid fluid, it is called a meningocele; an encephalocele contains 
 also some brain substance; while a protrusion formed by a diver- 
 ticulum of one of the ventricles is called a hydrencephalocele or an 
 encephalocystocele. It formerly was believed that the most frequent 
 form was the meningocele; but, though the protrusion resembles 
 this macroscopically, histological study has proved that most cases 
 
554 SURGERY OF THE HEAD 
 
 really are encephalocystoceles, as the cavity of the cyst is lined by 
 ependymal cells, which are directly continuous with those of the 
 ventricles of the brain, while the cyst walls are formed by an 
 attenuated layer of cerebral tissue. 
 
 The diagnosis usually is not difficult, though deep lying dermoids, 
 in contact with the dura mater, and having its motions transmitted 
 to them, sometimes are mistaken for cephaloceles. The prognosis is 
 poor, most infants either dying soon after birth, or presenting in 
 later life evidences of cerebral defects (porencei)hal()n, liydrocephalus, 
 idiocy, etc.). Spina bifida often coexists. 
 
 Treatment. — Protection should be afforded the tumor, to prevent 
 excoriation and infection. In most cases little else can be done; 
 but if there is only a small channel of communication with the cranial 
 cavity, and if the child's mentality appears normal, removal of the 
 tumor may be attempted, with closure of the skull defect by trans- 
 planting a bone flap from a neighboring portion of the skull. 
 
 Microcephalus. — When the skull is abnormally small, the child 
 often is idiotic or feeble-minded. Keen (1890), Lannelongue (1891) 
 and others have done linear craniotomy for this condition, on the 
 theory that premature ossification of the cranial sutures caused 
 compression of the brain, and that division of the cranium in a line 
 parallel with the sagittal suture would allow the brain to expand. 
 But the modern belief is that the smallness of the skull is the result 
 of lack of cerebral development, and is not the cause of it. Agnew 
 said the operation was no more use than cutting a piece out of a 
 turtle's shell, to make him grow larger; and this is the general belief 
 of surgeons of today. There is no surgical treatment for idiocy. 
 
 Hydrocephalus. — This is a symptom of some disease of the brain 
 or its mem})ranes, interfering with the normal circulation of the 
 cerebrospinal fluid, and causing it to collect in abnormal amounts 
 on the surface of the brain or within its ventricles. Hydrocephalus 
 thus is classified as external and internal; and it may be acute or 
 clironic, congenital or acquired. 
 
 External Hydrocephalus, in which the fluid collects in the sub- 
 arachnoid space, is very rare; many cases designated by this name 
 really are properly classed as other conditions. There may be acute 
 edema of the subarachnoid tissues, as the result of trauma; the 
 "acute serous meningitis" of Quincke (1893) belongs here, as also 
 does "hydrops ex vacuo," in which fluid collects and fills the space 
 left by skrmkage of the brain from injury or disease. 
 
 Internal Hydrocephahis. — This is met with in two distinct forms, 
 the congenital and the acquired. 
 
 Acquired Hydrocephalus usually results from obstruction or actual 
 occlusion of the foramina at the base of the brain, by which the 
 cerebrospinal fluid leaves the ventricles; and the most frequent 
 cause is a basal meningitis, generally tuberculous (p. 579). Each 
 lateral ventricle communicates with the third ventricle tlirough a 
 foramen of IMonro; while in the roof of the fourth ventricle (which 
 
// } ■ DROCEPHA L US 555 
 
 (IniiiLs the third ventricle through the aqueduct of Sylvius) are found 
 the foramina of Key and Retzuis, and that of IVIagendie, which are 
 the channels of coinnuniication between the ventricular ca\ities 
 and the suharachnold space of the brain, this being contiinious with 
 the subarachnoid space of the chord. Occlusion of one foramen of 
 Monro may cause unilateral hydrocephalus. Though most cases 
 of acquired internal hydrocephalus are due to basal meningitis, yet 
 ejMMidynial inflammations, or pressure of a brain tumor causing 
 obstruction of the \eins of (ialen sometimes are resj)onsil)le for the 
 condition by })roducing edema from venous stasis. The syinptoms 
 of the acquired form of internal hydrocephalus are those of the causa- 
 tive condition complicated by cerebral compression (p. 573); and 
 the treatment consists in relieving the compression, as removal of the 
 cause of the obstruction usually is out of the question. Lumbar 
 puncture (p. 157) is useless, as the occlusion of the basal foramina 
 prevents evacuation of the ventricles by this route; and such treat- 
 ment may prove quickly fatal by withdrawing the support of the 
 cerebrospinal fluid from beneath the medulla, and allowing the sui)er- 
 incumbent pressure to crowd this down into the foramen magnum 
 (p. 574). But as a palliative 
 measure repeated tapping of the 
 lateral ventricles may be done 
 (v. Bergmann, 1888) through 
 a trephine opening at Keen's 
 point (1888): this is 3 cm. be- 
 hind and an equal distance above 
 the external auditory meatus; 
 the needle is entered through 
 the posterior part of the first 
 temporal convolution, and is ' .— - 
 
 directed toward the summit of Fig. 606.— Shaded portion on surface of 
 
 ,1 •, • ,1 , • 1 the brain indicating the position of the 
 
 the opposite pmna; the ventricle lateral ventricle within. (Campbell.) 
 
 should be reached at a depth of 
 
 about 4 cm. Kocher's point (1894), is 2.5 cm. to 3 cm. from the median 
 line and 3 cm. anterior to the precentral fissure (see Cranio-cerebral 
 Topography, p. 567) ; the needle is directed downward and backward 
 and enters the ventricle at a depth of 4 or 5 cm. Fig. 606 illustrates 
 the relative position of the lateral ventricles to the surface of the brain. 
 Or a large area of bone may be removed from the cranium, relieving 
 the ventricular pressure by allowing hernia cerebri as in the operation 
 of decompression for brain tumor (p. 589). 
 
 Congenital Hydrocephalus. — In these cases there is no obstruction 
 or obliteration of the foramina at the base of the brain, but for some 
 reason the cerebrospinal fluid collects in excessive quantities, and 
 as this condition supervenes in fetal existence, or soon after birth 
 before the cranium is ossified, there are no symptoms of cerebral 
 compression, but progressive enlargement of the cranium occurs, 
 and the typical hydrocephalic head is produced (Fig. 607). A fair 
 
556 SURGERY OF THE HEAD 
 
 degree of intelligence may be preserved, but in cases of extreme 
 deformity the size and weight of the head may render the child help- 
 less, and in most cases death from malnutrition occurs within the 
 first two years of life. Spina bifida sometimes complicates the case, 
 and paralyses of the limbs are not uncommon. Rarely is the disease 
 arrested spontaneously. 
 
 Fig. 607. — Congenital inteinal hydrocephalus of moderate grade. Age seventeen 
 months. Episcopal Hospital. 
 
 Treatment. — Keen (1891) and Sutherland and Cheyne (1898) 
 attempted to drain the ventricles into the subarachnoid space (intra- 
 cranial drainage), whence they thought the fluid could readily be 
 absorbed by the veins which discharge into the longitudinal sinus. 
 Cheyne used strands of catgut for this purpose, and others have 
 used various materials, including gold and silver tubes. N. Senn 
 (1903) drained into the siihcuianeous tissues. But the immediate 
 mortality was unduly high, and no permanent benefit was secured 
 in those patients who recovered, so that the operation has been 
 abandoned. Gushing (1908), having due regard for the fact that 
 in these congenital cases there rarely is any obstruction to the circula- 
 tion of the cerebrospinal fluid at the base of the brain, inferred thence 
 that the obstruction must be where the cerebrospinal fluid enters 
 the blood vascular system {i. e., in the region of the longitudinal 
 sinus) ; on this account he held it to be useless to attempt to establish 
 an outflow by Keen's and Cheyne's method; but he proposed, after 
 ascertaining that the ventricles could be drained by puncture of the 
 lumbar spine, to divert the fluid thence into the retro-peritoneal 
 tissues by means of a silver tube passed through the body of one of the 
 lumbar vertebrae. He has done this operation twelve times "with a 
 considerable measure of success." Heile (1910), in an infant of two 
 days old, successfully employed Handley's operation (p. 270), con- 
 necting the sac of a spina bifida with the peritoneal cavity by means 
 of subcutaneous silk threads; a complicating hydrocephalus also 
 disappeared. On the theory that the excess of cerebrospinal fluid 
 
INJURIES OF THE SKULL bbl 
 
 is not due to (laiuiiiiiij,' up hut to liyiuTsecretion, Stiles (1905) has 
 practised ligation of both common carotid arteries, at an interval of 
 three weeks, and feels encouraged hy the results. 
 
 INJURIES OF THE SKULL. 
 
 Wounds. — Occasionally one sees incised wounds of the cranial 
 bones, without fracture; sabre wounds sometimes occur in war, and 
 in civil life a pen-knife or other sharp instrument may be stuck 
 into the skull. Such injuries require no special treatment beyond 
 removal of the foreign body, if still present, and antiseptic care of 
 the wound. If the implement is so firmly embedded in the skull that 
 it cannot be withdrawn, as was the case with a pen-knife wound of 
 the skull which I treated when interne at the P'piscopal Hospital (the 
 point of the blade having broken off), and if it is certain that the 
 cranial cavity has not been penetrated, it will be safe to wait a few 
 hours until reactive processes in the surrounding bone have begun, 
 when the implement may be extracted easily. Otherwise the surround- 
 ing bone must be removed with gouge, and the object extracted. 
 
 Fractures. — For practical purposes the skull may be considered 
 a sphere, possessed of a considerable degree of elasticity. For it 
 to be fractured, a good deal of force is necessary, and this acts in two 
 main ways: (1) the skull may be compressed between two diametric- 
 ally opposite forces, or (2) it may be struck a violent blow. In the 
 latter case the effect is the same whether the head is struck, or whether 
 it strikes against another object; the only counter-pressure in the 
 former case is that offered by the inertia of the head and the resist- 
 ance of its attachments to the trunk, while in the latter there is also 
 the momentum of what Archibald happily terms the "after-coming 
 head." Between the diffused crush and the localized blow, there 
 may be all grades of violence, varying from the puncture made by a 
 pick-axe, or the blow from a black-jack, to a knockout by a sand-bag, 
 or a crush between two heavy beams. 
 
 When the cranium is compressed in one diameter it naturally 
 expands in the diameter at right angles to the first (Saucerotte, 
 1769); Victor Bruns (1854) and Angus McLean (1912) measured this 
 compensatory expansion experimentally, finding that it amounted 
 to several millimeters. The first and most obvious result of this 
 compression was illustrated by Ali Krogius (1907) by cracking a 
 hazelnut by lateral compression (Fig. 608): fissures are produced 
 which represent meridians of longitude in relation to the points of 
 compression w^hich are regarded as poles; these fissures gape widest 
 in the equatorial region, and when compression is relaxed they may 
 close again completely. In the skull such fissures are very frequently 
 seen as the result of diffused violence, and in them may be caught, 
 as in a vise, hairs from the scalp, portions of felt from a hat, and 
 strangest of all, foreign bodies may even pass through the fissure while 
 it momentarily gapes, and thus be entirely hidden from view inside 
 
558 
 
 SURGERY OF THE HEAD 
 
 the cranium when the closed fissure is examined by the surgeon. 
 These are called hiirsiing fractures (von Wahl, 1883). 
 
 Another result of the compensatory expansion of the skull in the 
 diameter at right angles to that in which it is compressed, is that at 
 the poles there occurs an inbending of the skull (Figs. 609 and 610); 
 that such should be the case at the point of impact of localized vio- 
 lence, is not difficult to understand, but that a fracture from inbend- 
 ing may occur at a point more or less remote would be luithinkable 
 unless the elasticity of the skull and ordinary physical laws were 
 kept in mind. This is the fracture by counter-stroke (contrecoitp) , 
 which formerly was explained solely on the basis of vibrations which 
 were set up by the blow, and spreading in all directions from the 
 
 Fig. 60.S. — Mer-hanism of fracture 
 of the skull by lateral compression: 
 a meridional bursting fracture. 
 
 Fig. 609. — Diagram to illustrate the elas- 
 ticity of the skull. When the skull is com- 
 pressed between a and b, these points ap- 
 proach each other while the points c and d 
 become more widely separated. (See Fig. 
 609.) 
 
 Fig. 610. — Mechanism of fracture of the 
 skull by counter-stroke: when the skull is 
 compressed at a, a and b approach each 
 other, and a fracture by inbending maj' occur 
 at b as well as at a; or fracture by outbending 
 may occur at c or at d. 
 
 point of impact met finally at the polar point and there disrupted 
 the skull. Though the bursting theory, originated by Chopart and 
 other French surgeons in the eighteenth century, and re-introduced 
 and elaborated by Felizet in France (1873), by Messerer and von 
 Wahl in Germany, and by Dulles in America, in the eighth decade 
 of the last century, has largely superseded the vibratory theory as 
 an explanation of fissured fractures and fractures by counter-stroke, 
 there can be no doubt, as pointed out by Xancrede (1884), that 
 vibrations do occur, and are most violent where the bone is thickest, 
 that is, at the base of the skull, where most of the fractures by 
 counter-stroke occur. 
 
 When localized violence is applied to the skull the force of the 
 blow expends itself mostly by depressing the bone at the point struck; 
 
INJURIES OF THE .SKILL 
 
 r)5<) 
 
 this is the inhnuliiig frnriiire referred to above. Now, this j)oiiit 
 l)eiii<; rej^'iirded as a pok', there are j)r<)(hiced in the surrouiidiiijf 
 inert l)iit ehistic skull, eoneeiitric areas of eompression, or outbrnditu/.s, 
 which rei)rescnt parallels of latitude; and at the points where the 
 inhending and outhending* areas meet, a circular fissure or ring 
 frdcfurr may result (Fig. (111). 
 Occasionally a long fissure oc- 
 curs at the ('(juatorial region 
 when the skull is flifi'usely 
 crushed, and, according to 
 Archihald, this must he ex- 
 plained as a fracture by out- 
 bending, as must certain fis- 
 sures which run at right angles 
 to the meridional bursting fis- 
 sures (Fig. ()12). 
 
 In addition to the usual clas- 
 sification of fractures, as simple, 
 compound, depressed, etc., 
 there are important clinical dis- 
 tinctions between fractures of 
 the vault of the skull and those 
 of its ba.se. 
 
 Fractures of the Vault of the Skull. — ]\Iost fractures of the vault 
 are due to direct violence, the parietal and temporal bones being 
 most often injured. Almost always the injury acts from outside the 
 
 ^»^ 
 
 Fig. 611. — Ring fracture of skull. From 
 a specimen in the Mutter Museum of the 
 College of Physicians of Philadelphia. 
 
 Fig. 612. — Burstinj; fracture of skull from diffused violence on vertex: fissure radiating 
 to base and widest at equator (temporal region) ; with outbending fracture (just below- 
 parietal eminence) at right angles to main fissure. From a specimen in the Mutter 
 Museum. 
 
 skull, SO that the inner table is in the line of extension (Fig. 613), 
 and, therefore, is more widelv fractured than the external table 
 
 ^ The Flachbiegung unci Krumbiegung of Treub (1884). 
 
560 
 
 SURGERY OF THE HEAD 
 
 ;,a^^^^l 
 
 
 ^^fe**:-. 
 
 t^^^e^^^^^c^,;^;^'^^.?^*^ 
 
 Fig. 613. — Teevan's diagram to show 
 that the inner table often is more exten- 
 sively damaged than the external, because 
 it is in the line of extension. 
 
 (Teevan, 1864). Indeed, so elastic is the skullthat a fracture of the 
 vitreous table may occur without any fracture of the outer table. 
 In the rare cases, mostly suicidal pistol shots, in which the cranial 
 vault is fractured from violence within the skull, the outer table is 
 more widely fractured than the inner. It is very unusual for the 
 
 external table to be fractured 
 without injury of the internal; 
 it is then depressed into the 
 diploe. In 1909 I trephined for 
 such an injury, in a boy, aged 
 thirteen years, at the Episcopal 
 Hospital, Philadelphia. The 
 amount of splintering is in in- 
 verse ratio to the momentum 
 of the body fracturing the skull; 
 but in the case of gunshot 
 wounds, as pointed out at p. 
 188, the "explosive action" is 
 manifested at close range. 
 
 Symptoms. — Apart from those 
 due to intracranial complications 
 (p. 569), there are no symptoms specially indicative of a fracture of 
 the vault of the skull. The diagnosis rests on the history of injury, 
 on the symptoms due to complicating intracranial lesions, and on 
 physical signs. A skiagraph may be of value. If there is no scalp 
 wound, the entire calvaria must be palpated carefully and persistently 
 to discover any evidence of fracture; if a mere fissure exists, without 
 depression or separation, nothing will be detected beyond the signs 
 of contusion of the scalp (p. 551). The error of mistaking a hema- 
 toma for a depressed fracture must be guarded against. If there is a 
 depressed fracture it usually is possible to feel it tlirough the scalp, 
 recognizing its jagged outline and its actual depression below the 
 surrounding bony surfaces; the depressed fragments may not be 
 impacted, and injudicious pressure may drive them against the brain. 
 If the existence of a fracture remains in doubt, no hesitancy should 
 be felt in making an incision down to the bone, under proper anti- 
 septic precautions, and inspecting the bared cranium. In compound 
 fractures it may be necessary to enlarge the existing wound for the 
 same purpose. A normal suture may be distinguished from a fissured 
 fracture by its anatomical position, its greater irregularity of outline, 
 and by the fact that a fracture cannot be washed clean of blood. 
 In children there may be diastasis of suture lines instead of, or in 
 addition to, fissured or depressed fracture of the skull. ^ 
 
 Prognosis. — This is good, so far as the fracture alone is con- 
 cerned. It is only intracranial complications that render the outcome 
 doubtful. Excessive loss of bone seldom occurs, and complications 
 affecting the scalp (erysipelas, etc.) are very rare with antiseptic 
 methods. 
 
 ^See footnote, p. 561. 
 
ISJIRIES OF THE SKILL 'yiW 
 
 Trcdfinrnf. — EvtTv case of liead injury, no matter how trivial in 
 appearance, should he treated with extreme circumspection. It 
 is the custom of many cautious surjjeons, and for .\-ears has been 
 mine, to urjije all patients with injuries of the head to remain under 
 constant surgical observation, preferably in the hospital, for several 
 days. It is most important to prevent infection; and, as a rule, it is 
 well to shave the entire scalp, as this often renders diagnosis easier, 
 and always promotes asei)sis. Shaving the scalp, or at least a wide 
 area around the injury, therefore, usually is the first step in treatment. 
 
 // onI}/ a fdinpJr fissured fracture exists, without depression, and 
 without any c\idcnce of intracranial mischief, it is sufficient to keep 
 the j)atient in bed for six to eight days, with an ice l)ag to the head; 
 the bowels should be well opened, preferably by calomel, as this 
 has a specific action upon the meninges and brain, exerting w^jat 
 was known in the last century as an "anticipatory antiplastic action," 
 that is, pre\enting excessive inflammatory reaction, probably by 
 its antiseptic properties. Urotropin is used for the same purpose, 
 as it has been found to circulate in the cerebrospinal fluid; it must 
 be given in very large doses. If the simple fissured fracture was 
 caused by localized violence, which is rarely the case, it will be safer 
 to ascertain whether or not the inner table is splintered, by removing 
 a button of bone with the trephine. If such splintering exists, the 
 case is treated as a depressed fracture. 
 
 If the fissured fracture is compound the surgeon should make very 
 certain that no hair or other foreign body is caught in the fissure, 
 or has passed through it, before he decides against operation. If 
 there is any doubt as to the surgical cleanliness of the fissure, the 
 surgeon must take means to render it aseptic as soon as the patient 
 recovers from the shock of the accident. Sometimes little tufts of 
 hair are found sticking up out of almost invisible fissures (G. G. 
 Davis, 1910), and a gouge must be employed to remove them and 
 their containing bone; in other cases a trephine may be used to per- 
 forate the skull, and then the entire septic fissure is gnawed away 
 into healthy bone by rongeur forceps.' 
 
 // the fracture is depressed I believe operation always in indicated, 
 to relieve pressure on the brain; and if it is compound, whether it is 
 depressed or not, operation usually is necessary to secure asepsis of 
 the wound. But operation has no virtue of its own, being only a 
 mechanical means of fulfilling plain therapeutic indications. Loose 
 
 ' In 1907 I operated on a boy of eleven years, at the Episcopal Hospital, Phila- 
 delphia, for extensive bursting fracture due to crush; there were compund com- 
 minuted depressed ring-fractures in the right parietal and the left temporal bones, 
 the poles of impact; and these areas were connected across the vault by a meridi- 
 onal fissure which was deflected into the suture lines, causing diastasis of the right 
 temporo-parietal suture and the entire coronal suture, with rupture of the long- 
 tudinal sinus. The loose fragments were removed, the depressed fragments 
 elevated, and the separated sutures cleaned of hairs and clot by gnawing away 
 both margins of bone. From the left temporal region a fissure ran to the base, 
 thus practically separating the skull into antero-posterior halves. There was 
 no injury to the brain, and the boy recovered. 
 36 
 
502 
 
 SURGERY OF THE HEAD 
 
 fragments are removed, and the elevator (Fig. 614, 3) is passed under 
 the depressed fragments and these are pried up into place. Search 
 is then made by Horsley's dural separator (Fig. 614, 2) for loose frag- 
 ments which sometimes are driven under the neighboring intact por- 
 tions of cranium, and these are removed. All fragments completely 
 detached should be removed entirely; they will not reunite if left in 
 place, and may undergo necrosis or cause infection. At best they 
 would act only as decalcified bone might, as an inorganic basis into 
 which surrounding osteoblastic cells might grow. If the fragments are 
 impacted, so that none of them can be removed, and there is no crack 
 into which the elevator can be insinuated, a button of bone must 
 
 Fig. 614. — Instruments used in operating for fracture of the skull: 1, Crown trephine; 
 2, Horsley's dural separator; 3, bone elevator; 4, Hopkins's rongeur forceps. 
 
 be removed by the crown trephine (Fig. 614, 1), and the remaining 
 depressed fragments ele\'ated through the opening thus made. Next, 
 the bone must be disinfected. Usually this is best accomplished by 
 biting oflF ragged edges of bone with the rongeur forceps (Fig. 614, 4), 
 thus completely removing all suspicious areas in which foreign par- 
 ticles may have been caught. In fractures of the frontal siiwses the 
 outer w^all alone may be fractured; but as the sinuses are of uncer- 
 tain extent, even when developed, and as the fracture always is 
 compound, either from within or on the skin surface, it is proper 
 to explore the region affected, and to remove sufficient bone to render 
 the wound surgically clean. 
 
 After any operation for fracture of the skull, a copious dressing 
 
INJURIES OF THE SKULL 
 
 o(J3 
 
 should be securely applied (Fig. 015), as the patient may he delirious, 
 and reciuires mechanical protection to the site of operatif)n. 
 
 liupturc of the longitudinal sinus is a not infrc(iuent complication 
 of fractures of the cranial vault. H. K. Wharton (1901) collected 
 70 case reports. Bone fragments may be embedded in its walls, 
 or it may be torn accidentally in elevating or removing depressed 
 fragments. Hemorrhage may be profuse, but it is readily controlled 
 by packing, as the blood-pressure is low. Attempts to suture the 
 rent rarely are successful, the sutures tearing out; and the profuse 
 hemorrhage may cost the patient his life before the attempts to suture 
 are abandoned. Packing is quicker and safer. The gauze should be 
 removed in three or four davs. 
 
 
 ^ 
 
 
 ■ 
 
 Fit:. 61.5. — Dressing for fracture of skull. Episcopal Hosijital. 
 
 Trephining the Skull. — The trephine is applied first with the centre- 
 pin protruded; with this as a pivot a circular groove is cut by alter- 
 nately supinating and pronating the hand, and when this groove is 
 of sufficient depth to steady the trephine without the aid of the 
 centrepin this is withdrawn, and the trephining is continued very cau- 
 tiously, using scarcely any pressure for fear of plimging the instru- 
 ment into the brain. The use of Gait's conical trephine' renders this 
 accident unlikely, if ordinary prudence is exercised. When the 
 diploe is reached, the trephine cuts more easily, and the bone bleeds 
 more; as the vitreous is approached the surgeon, from time to time, 
 should test the depth of his groove with the fiat end of a probe, as 
 the skull is not of uniform thickness and incautious trephining may 
 rupture the dura at one side before the vitreous table is cut through 
 on the other. If the button of bone does not come away in the crown 
 of the trephine, it is pried out by the elevator. The trephine never 
 should be applied on the depressed fragment, but on the surrounding 
 intact cranium, so that no further impaction or cerebral injury may 
 be produced. Nor should the trephine be applied directly over the 
 longitudinal or lateral sinuses. 
 
 Hudson s Trephine (1909) is a modification of Doyen's burr (1896), 
 an instrument like a carpenter's brace and bit; the burrs of Hudson's 
 
 1 Thi.s was a revival of an old instrument. Gait's pattern was first used by 
 Sayre in 1861 : the spiral grooves on the periphery act as a wedge so long as there 
 is counter-pressure by bone on the oblique teeth of the crown; when resistance 
 ceases, the spiral grooves act as a screw, and the trephine binds. Hudson's 
 trephine (p. 588) is constructed on the same principle. 
 
5()4 
 
 SURGERY OF THE HEAD 
 
 instrument (Fig, 628) are made with spiral cutting grooves, so that 
 unless something solid like bone is pressed upon by the point, the 
 instrument will bind, thus rendering imj)ossible an injury to the 
 dura. This is the same principle on which Gait constructed his 
 conical trephine. 
 
 Fractures of the Skull in the Newborn. — Indentations of the semi- 
 membranous skull of the baby may occur from injury during labor, 
 or at a later age from blows, falls, etc. The bone is so flexible that 
 true fracture during labor is rarer than bending. The depression 
 usually corrects itself within ten days; if it does not, and immediately 
 if it produces symptoms of cerebral compression (p. 570), operation 
 should be done. Nicoll's operation (190.S) consists in excision of the 
 cup-shaped depression, and its replacement with the dural (convex) 
 surface beneath the skin. Usually it is sufficient to pry the bone 
 up by an elevator introduced through a neighboring fontanelle or 
 suture. The bone is soft and easily cut by scissors. Some surgeons 
 use a corkscrew for an elevator. The danger of leaving such fractures 
 untreated is that cortical lesions may result, leading to spastic par- 
 alysis, epilepsy, imbecility, etc. Commandeur (1910) has collected 46 
 such operations, with three deaths from infection. In older infants 
 fracture may split the cranial bone radially in the usual line of 
 ossification. 
 
 Fractures of the Base of the Skull.— Most of these are the result of 
 bursting force, a fissure extending from the point of injury on the 
 
 vault to the base of the skull, usually 
 along definite lines. The recognition 
 of this fact is due chiefly to Aran 
 (1844), who claimed that in every 
 fracture of the base the fissure 
 began in the vault. This, how- 
 ever, is not literally true, as the 
 fracture sometimes begins at the 
 base and may or may not extend 
 to the vault. Falls on the feet or 
 on the buttocks may fracture the 
 base by force applied through the 
 condyles of the occipital bone. 
 When fracture of the base occurs 
 as part of a bursting fracture from 
 diffused force applied to the cah-aria, 
 the fissure extends to the base by 
 the shortest anatomical route, 
 avoiding buttresses such as the 
 mastoid, the external angular pro- 
 cess of the frontal bone, etc. Thus 
 it is found that in fractures from lateral compression, usually on the 
 parietal bones, the fissure crosses the middle fossa of the skull in the 
 majority of cases (23 out of 32 cases recorded by Archibald). From 
 
 Fig. 61G. — Diagram allowing the 
 usual course taken by fissured fractures 
 of the base of the skull. 
 
INJURIES OF THE SKULL 565 
 
 occi pita-frontal compres.s'ion, a fissure results which passes usually 
 thr()U<:;h oue orbital plate of the frontal, through the body of the 
 sj)iuMioi(l, and the sella turcica, along the petro-occipital suture to 
 the jugular foramen, and perhaps up again to the vault along the 
 niasto-occipital suture; or if the fissure passes down the occipital 
 bone, it skirts the side of the foramen magnvnii, and so to the sella 
 turcica (Fig. ()1()). Uawling found the sphenoidal sinus fractured in 
 70 per cent, of his cases. These basal fractures very often are com- 
 pound, through the nas()-i)harynx or middle ear. Displacement is 
 very slight. 
 
 Punctured fractures of the base of the skull are exceedingly serious 
 lesions; they occur from such implements as umbrella tips, pencils, 
 pipe-stems, etc., which may penetrate the orbit or naso-pharynx, 
 sometimes entering one of the fissures or foramina at the base of the 
 brain with little damage to the surrounding bone. 
 
 Symptoms. — These depend, as in fractures of the vault, much 
 more upon cerel^ral injury than upon the mere existence of fracture. 
 The diagnosis, therefore, depends in large measure on circumstantial 
 evidence derived from certain physical signs, and from a knowledge 
 of the mode of injury. Fractures of the anterior fossa may be accom- 
 panied by bleeding into the retrobulbar tissues of the orbit, sub- 
 conjuncti\al ecchymosis appearing some days after the injury, and 
 spreading from behind forward; exophthalmos is a rare sign. Bleed- 
 ing from the nose or mouth is as often due to extracranial as to cranial 
 lesions. Brain substance or cerebrospinal fluid rarely is discharged. 
 Blood may be swallowed and vomited. Fractures of the middle fossa 
 frequently are compound through the middle ear, and though bleed- 
 ing from the ear may be due merely to rupture of the tympanic mem- 
 brane, when persistent or profuse it has usually an intracranial source ; 
 it may enter the throat through the Eustachian tube. A clear liquid 
 discharge may occur from the mastoid cells or from the membranous 
 labyrinth, but any such discharge in large amount is more apt to be 
 cerebrospinal fluid. Paralysis of one or more of the cranial nerves 
 is more frequent in fractures of the middle fossa than in those of 
 the anterior or posterior fossa^. The seventh and eighth nerves are 
 those most often injured, usually from laceration or secondary edema. 
 Ferron (1908) collected 339 instances of nerve lesion, with 33 deaths. 
 Fractures of the posterior fossa frequently are not recognized, because 
 of lack of physical signs. Ecchymosis over the mastoid, appearing 
 some days after the injury, is of some significance; as is the occasional 
 involvement of the ninth, tenth, and eleventh nerves. 
 
 Prognosis. — This depends upon the presence of intracranial lesions 
 and upon the development of complications, especially meningitis. 
 Without these, the prognosis is no worse than in fracture of the 
 vault. As a general rule, about one out of three or four patients 
 with fracture of the base will die within a week or ten days. 
 
 Treatment.— The general treatment is the same as in fractures 
 of the vault: physical and mental rest, in a cool, darkened room; 
 
500 
 
 SURGERY OF THE HEAD 
 
 and purgation to remove material which might cause toxemia or bac- 
 teremia and hence increase the danger of sepsis. Urotropin should 
 be administered (15 grains tliree times daily, with an interval of one 
 day at the end of each three-day period), and liquid diet should be 
 continued until danger of complications has passed. The naso-pharynx 
 and external auditory meatus should be cleansed, but repeated 
 irrigation is more apt to encourage sepsis than to prevent it. If 
 bleeding is profuse it may be necessary to pack the naso-pharynx 
 or auditory meatus; in all cases it is well to keep a little sterile ab- 
 sorbent cotton in the latter channel to absorb discharges. If bleeding 
 is very persistent, and especially if packing produces symptoms of 
 cerebral compression, attempt should be made, by trephining the 
 skull low in the temporal region, to reach the source of hemorrhage 
 and deal directly with it. If symptoms of compression arise, whether 
 there is external hemorrhage or not, decompression should be done 
 (p. 589). Nassau (1912) not only does decompression, but opens the 
 dura, and lightly packs the arachnoid spaces with gauze; he claims 
 that this is the only efficient method of controlling intradural hemor- 
 rhage (p. 575). Four days later the patient is again anesthetized, the 
 gauze is removed, the dural flap sutured, and the scalp closed. Lumbar 
 puncture may be employed as a diagnostic measure to ascertain the 
 
 presence of blood in the cerebrospinal 
 fluid; occasionally it is curative also. 
 
 Osteomyelitis. — Osteomyelitis of the 
 cranial bones is rare, and extremely 
 fatal ; usually it follows contusion of the 
 bone, secondary infection occurring 
 through the blood-stream or from an 
 overlying hematoma. It is rarer still 
 as a complication of compound fracture 
 or a scalp wound, as in such cases 
 drainage is free. The diagnosis rests on 
 the appearance of septic symptoms, after 
 injury to the skull, with the develop- 
 ment locally of the "puffy tumor" of 
 Percival Pott (1708), which is "a circum- 
 scribed, flattened, elevated swelling," 
 due to infiltration of the scalp with 
 serum, and indicates "a subjacent sup- 
 purative periosteitis, denuded bone, and 
 in many instances subcranial suppura- 
 tion with separation of the dura mater" 
 (Nancrede, 1885). 
 Treatment. — Treatment consists in removal of all diseased bone, 
 by trephine and rongeur, with free drainage. Death is the usual 
 outcome of the disease, from meningitis and encephalitis, except 
 where very early operation is done. 
 
 Fig. 617. — Loss of bone after 
 fractured skull: four months after 
 operation. (Dr. Mutschler's 
 case.) Episcopal Hospital. 
 
CRANIO-CKREHRA L TOI'Odh'A I'll Y ')()7 
 
 Repair of Cranial Defects, rsuallv alter operation for fracture 
 or other lesion of tlie skull, in which a lar^'c area of hone is removed, 
 the defect produces little inconvenience, beinj;; filled in by dense 
 fibrous tissue. Tliere is no tendency to liernia cerebri (Fi^. (iiil ) unless 
 intracranial tension is increased; on the contrary, the area usually 
 is depressed (Fifj;. ()17). Sometimes, from dural adhesions, or other 
 cause, this depressed area is a source of constant aimoyance, and 
 may subject the brain to slight injuries. If the symptoms are so 
 severe as to d(>mand relief, a pedunculated osteoplastic flap, composed 
 of scalp and outer table of the skull, may })e raised by chisel from the 
 neighboring healthy bone, and implanted into the defect (Konig, 
 IsyO), the denuded cranium being covered by a Wolfe graft; or, as 
 done by Frazier in a recent case at the Episcopal Hospital, a free 
 trans])lant, consisting of the outer table, may be removed from 
 another portion of the skull. 
 
 SURGICAL AFFECTIONS OF THE BRAIN AND MENINGES. 
 
 Cranio-cerebral Topography, which implies a knowledge of the 
 relation of intracranial structures (cerebral fissures and convolutions, 
 blood-sinuses, meningeal vessels, etc.) to the overlying skull, is not 
 now regarded as of so much importance as some years ago. This 
 is so both because these relations exhibit variations in different 
 persons, and because modern surgical technique enables the surgeon 
 to raise a large bone flap from the cranium, and expose the underlying 
 structures over a sufficiently wide area to permit of his recognizing 
 them rather by their relations to each other than by their relations 
 to the surface of the cranium. But there are a few landmarks which 
 it is indispensable for the surgeon to know. 
 
 The longitudinal simis runs beneath the sagittal suture from the 
 root of the nose to the inion; it lies within the falx cerebri, and extends, 
 with its annexed blood-lakes, for nearly an inch each side of the 
 median line, being broader behind than anteriorly. Usually it extends 
 further to the right than to the left of the median line. 
 
 The lateral sinus runs on each side, along the attachment of the 
 tentorium cerebelli, from the inion to the base of the mastoid; here 
 it passes dowmward, following the petro-mastoid suture to the jugular 
 foramen (Fig. ()19). The anterior and upper margin of the curve 
 wdiere the horizontal and descending (sigmoid) portions of the lateral 
 sinus meet, known as the knee (genu) of the lateral sinus, is about 
 2.5 cm. (1 inch) above and nearly 4 cm. (about 1^ inches) behind the 
 centre of the external auditory meatus. The sinus is about 12 mm. 
 (I inch) or more broad, and the "dangerous area," over which a tre- 
 phine or chisel should not be applied, includes a strip of bone nearly 
 2.5 cm. (1 inch) wide, overlying the course of the sinus. 
 
 The upper limit of the cerebral hemispheres corresponds to the 
 position of the superior longitudinal sinus. Their lower limit reaches, 
 in front to the upper margin of the orbit; laterally it passes from a 
 
568 
 
 SURGERY OF THE HEAD 
 
 point 12 mm. (| inch) above the external angular process of the 
 frontal bone, to the upper margin of the external auditory meatus, 
 and thence to the inion, along the upper border of the lateral sinus. 
 
 The fissure of Rolando runs from a point about 12 mm. (| inch) 
 behind the mid-point between glabella and inion, forward for nearly 
 8.5 cm. (8| inches), at an angle of about 70° with the sagittal suture. 
 If a square of paper (90°) is folded diagonally, so as to make two angles 
 of 45° each, and one of these folds is again doul)led on itself, so as 
 to make two angles of 22.5° each, it will be possible, by adding one 
 of these latter angles to the 45° angle, to construct off-hand an angle 
 of (')7.5°, or three-quarters of the original right angle. If, then, this 
 
 Fig. 618. — Relation of the chief fissures and convolutions of the brain to the surface 
 of the skull. The dotted line which is nearly horizontal indicates the fissure of S.vlv^ius; 
 this line runs from the external angular process of the frontal bone through a point 
 2 cm. below the parietal eminence (x), and its middle third corresponds roughly with 
 the Sylvian fissure. Note the positions of the cranial sutures. 
 
 angle (07.5°) is placed on the sagittal suture, so that its apex lies 
 12 mm. (I inch) behind the mid-point between glabella and inion, 
 the course of the Rolandic fissure will be approximately indicated 
 (Chiene, 1888). The relation of the other chief fissures and con- 
 volutions is sufficiently indicated in Fig. ()18. 
 
 The middle vieningeal artery, entering the skull by the foramen 
 spinosum, divides almost immediately into two branches. The anterior 
 branch runs forw'ard and upward and crosses the anterior inferior 
 angle of the parietal bone, near the pterion; thence it runs upward 
 toward the sagittal suture, lying behind and more or less parallel 
 to the coronal suture. Near the pterion it lies usually in a bony 
 groove or canal, and is frequently torn by splinters of bone, or ruptured 
 
CONCUSSION AND CONTUSION OF THE BRAIN 5G9 
 
 \)\ iiilu'iidiii^' or l)iirstiiif,' fractures at this point. It may also be 
 iiijuri'd at this |)()iiit 1)\ a trcpliiiie, so it is safer to expose it by a 
 trephine openin*,' in the niiddk' of tlie temporal fossa, say 4 em. 
 (1^ inches) posterior to the e.xternal anj^ular process of the frontal 
 bone, and 2.5 cm. (1 inch) above the zygoma (Fifj. (ill)). The pos- 
 terior branch runs iiori'/ontally backward across the scjuamous plate 
 of the tcni])oral bone, and crosses the teniporo-i)arietal suture within 
 about 2 cm. (f inch) of its posterior end; it may be exposed by a 
 trephine opening; about 2. .5 cm. (1 inch) below the parietal eminence. 
 
 Fig. 619. — Course of middle meningeal artery and lateral sinus, outlined upon 
 the surface of the skull. 
 
 Concussion and Contusion of the Brain. — The brain is an incom- 
 pressible structure suspended within a bony case by fibrous partitions, 
 chief of which are the falx and tentorium; it is held relatively immobile 
 at its base by the cranial nerves, bloodvessels, and processes of dura 
 mater, which pass through the base oi the skull. It is surrounded by 
 a small amount of cerebrospinal fluid, which is in greater quantity 
 toward the base, especially around the medulla; and its ventricles, 
 which are directly continuous with the subdural spaces (p. 555), 
 are filled with the same fluid. A blow upon the head causes not so 
 much a vibration or tremefaction of the brain substance, as a sudden 
 displacement of the brain as a whole; it is flung, as it were, against 
 the opposite side of the skull, and usually it is contused most at the 
 point of impact, or the polar point, or at the base, where the greatest 
 strain comes. The cerebellum is relatively little affected, because 
 of its protected position beneath the tentorium, because it floats 
 on a greater amount of cerebrospinal fluid, and because of the possi- 
 bility of downward displacement by crowding the medulla into the 
 foramen magnum. Some blows on the head, severe enough to cause 
 symptoms, produce symptoms which are so momentary and fleeting 
 that it always has been difficult to believe that they were attended 
 by structural change. And until modern methods of histological 
 study were developed, it happened not rarely that postmortem 
 
570 SURCERY OF THE HEAD 
 
 examination failed to disclose any lesion in the brains of those who 
 had actually died with symptoms due to "concussion." But it has 
 come to be recognized, largely through the investigations of Sir 
 Prescott Hewett (1870), that the condition of these brains is not one 
 of "concussion," as was formerly taught, but is the result of con- 
 cussion, and is characterized by contusion, compression, extravasation, 
 laceration, or inflammation in varying degrees. Of course, it cannot 
 be asserted categorically that histological changes always are present 
 in patients who recover at once from the symptoms of concussion, 
 because there is no opportunity of submitting their tissues to micro- 
 scopical examination at the time of injury; but the belief is quite 
 general, and I believe quite justified, that even when the symptoms 
 produced are the most insignificant, definite lesions exist, and that 
 these vary from temporary arrest of cell-action, with capillary stasis, 
 or the slightest grades of contusion, with punctate hemorrhages, 
 to distinct laceration, ecchymosis, exudation, and edema of the 
 brain and pia-arachnoid. Kocher teaches that the immediate and 
 temporary symptoms are the result of cerebral anemia, while uncon- 
 sciousness which lasts for hours or days is due to cellular changes. 
 
 Symptoms.-^As in all cases of injury, some degree of shock is 
 present, and it often is difficult to distinguish the symptoms of this 
 condition from those due to concussion of the brain. After a blow 
 on the head only such symptoms as dizziness, or disturbances of 
 vision (sparks, specks, etc.), may be observed. In more marked 
 cases there is momentary loss of consciousness, the patient falling 
 as one dead; or, when striking the head in a fall, lying motionless 
 for a few seconds, and then regaining consciousness and rising to his 
 feet before assistance can reach him. In typical cases, two distinct 
 stages may be recognized:^ (1) The patient at first lies motionless, 
 senseless, nearly pulseless, pale and cold, breathing feebly but natur- 
 ally; the pupils dilated or contracted, fixed or acting freely; perhaps 
 with involuntary discharge of feces and urine. He will swallow if 
 food is put into his mouth. From this first stage, which may last 
 many days, the patient may recover without further trouble, or he 
 may gradually sink and die without reaction; or the first stage may 
 last a few moments only, the patient having passed into the second 
 stage before the surgeon sees him. The disappearance of the first 
 stage, whether by passing into the second or by direct recovery, 
 commonly is marked by vomiting, (2) In the second stage the patient 
 is no longer unconscious, though much indisposed to speak or pay 
 attention to surrounding objects. If roused by a question, he will 
 answer, but peevishly or angrily, turning away as if displeased at 
 the interruption. His posture is peculiar: he lies habitually on his 
 side, curled up, with all his joints more or less flexed, and if a limb 
 is touched he draws it away with an air of annoyance. The eyelids 
 are kept firmly closed. The pulse, at first slow and weak, gradually 
 
 ' This description is copied, almost verbatim, from the Principles and Practice 
 of Surgery- of John Ashhurst, Jr. 
 
COMPRESSION OF THE HRAIN ')71 
 
 becomes more frequent and stronger; the l)reatliinfi; is easier, and the 
 surface regains its natural warmtii and color. This staj^e gradually 
 subsides, after se\eral hours or days, and as the patient rej^ains 
 ability and willingness to communicate with those around him, 
 he complains almost invariably of severe headache. If the cerebral 
 lesions have been marked, they may leave the j)atient with his mental 
 faculties permanently impaired; usually, however, in such an event, 
 the earlier symptoms will have been those of compression of the 
 brain rather than those recognized as due to concussion. 
 
 Treatment. — The patient should l)e laid horizontal, with the head 
 slightly elevated, in a darkened room; and throughout his illness 
 he should be protected from all noise. During the first stage, stimu- 
 lation for shock may be necessary. So soon as shock is recovered 
 from, the bowels should be evacuated, the urine drawn if necessary; 
 and moderate amounts of liquid nourishment should be administered. 
 During the second stage, cold should be applied to the head, while 
 restoration of cerebration may be hastened by the administration 
 of calomel, one-sixth of a grain every four hours, for its "anticipatory 
 antiplastic effect" (p. 561); and this may be continued for many 
 days, or until the patient is clear in his head. Should restlessness 
 or delirium supervene, it is well to administer, with each dose of 
 calomel, two or three grains of Dover's powder. The use of the mind, 
 in conversation, reading, etc., should be resumed very gradually, 
 and convalescence should be prolonged, the patient living by rule 
 for many months after apparent recovery, and remaining under 
 surgical observation until by the lapse of time the absence of com- 
 plications from unrecognized cerebral lesions is assured. 
 
 Compression of the Brain. — As already stated, the brain is an 
 incompressible structure; its bulk can be reduced only by loss of 
 its fluid constituents; if compressed in one direction it must expand 
 in another. Experimental compression of the brain produces first 
 a stasis in the smaller venous channels; the longitudinal sinus col- 
 lapses; the blood cannot escape from the skull. If pressure increases 
 the arterioles may be affected. Normally changes in intracranial 
 vascular pressure are compensated for by the ebb and flow of the 
 cerebrospinal fluid. This drains away into the veins, and these 
 in turn empty mostly into the longitudinal sinus and certain emissary 
 veins through the diploe. Increase in vascular pressure from the arte- 
 rial side is easily and rapidly compensated for by venous absorption 
 of cerebrospinal fluid; and obstruction to the venous outflow (often 
 seen in cases of cervical or thoracic neoplasms) does not prove inju- 
 rious so long as the collateral diploic veins are open, or so long as the 
 cerebrospinal fluid can pass into the spinal canal and escape into the 
 venous circulation by that channel. But if the pressure on the venous 
 side becomes so great as to dam the blood back into the capillaries, 
 these side escapes become blocked, the brain may be forced dowm 
 until the medulla chokes off the outlet for cerebrospinal fluid through 
 the foramen magnum, and symptoms of "compression" appear. 
 
572 SURGERY OF THE HEAD 
 
 It was shown experimentally by Althann, in 1871, and since his 
 time by numerous other investigators, that "the effect of space 
 diminution in the skull was identical with that of any other process 
 which hindered cranial circulation" (Archibald, 1908); so that, as 
 pointed out l)y von Bergmann (1880), the symptoms of "compression" 
 are due not to actual compression of nerve elements, but to cerebral 
 anemia. 
 
 The maintenance of life depends on the functioning of the chief 
 medullary centres, ^'as()motor, vagus, and respiratory; and it is to 
 interference with the circulation of these centres that the most strik- 
 ing symptoms of cerebral compression are due. Localized compression 
 produces the so-called focal symptoms, i. c., paralysis; while general- 
 ized ■ compression, which may develop independently of, or may 
 succeed, local compression, is particularly characterized by bulbar 
 symptoms: interference with the centres already named; but in 
 generalized compression there also usually is unconsciousness, from 
 cortical compression. 
 
 So soon as anemia affects the medulla, the vasomotor centre is 
 stimulated, blood-pressure is raised higher than intracranial (extra- 
 vascular) pressure, blood again reaches the medulla, and life is pro- 
 longed, at least temporarily (von Schulten, 1885). But the stimulus 
 of anemia then being removed, blood-pressure sinks somewhat, as 
 intracranial pressure continues to increase, and anemia of the medulla 
 again occurs; whence renewed stimulation of the vasomotor centre, 
 a further rise in blood pressure, and again a temporary relief of the 
 medullary anemia. Cushing (1902, 1^0-3) has been able to follow 
 these successive periods of anemia and return of circulation by obser- 
 vation of the cerebral cortex of monkeys through a trephine opening; 
 and his experiments justify the conclusion that similar changes occur 
 in the medulla. 
 
 This alternate stimulation and depression of the medullary centres 
 explains the more or less periodic phases observed in the blood- 
 pressure and respiration curves obtained from such patients. They 
 are known as Traube-Hering waves. The respiratory phases closely 
 resemble the Cheyne-Stokes type, the stage of apnea occurring when 
 the respiratory centre is deprived of blood, and the hyperpnea develop- 
 ing when circulation is restored by increase in blood-pressure. This 
 "life and death struggle," as von Schulten termed it, may continue 
 until blood-pressure reaches enormous heights; Cushing raised it 
 experimentally to 290 mm. Hg.; but unless intracranial pressure is 
 relieved, the medullary centres in time will cease to react, and 
 sudden fall of blood-pressure will occur, followed by death. "Death 
 probably always occurs from primary failure of the vasomotor centre, 
 rather than from that of the respiratory, as has been asserted by 
 some. The vasomotor centre holds the key to the position. Its 
 defeat involves that of the respiratory and vagus centres; and with 
 their defeat the whole armv is devoted to slaughter." (Archibald, 
 1908.) 
 
COMPRESSION OF THE JiliAIN nl'.^ 
 
 Causes. — Anything; which increases iiitracrania] pressure may 
 cause symptoms of compression of the brain. This inchides: (1) 
 Foreign bodies driv'cn against or into the brain (bone fragments, 
 l)ullets, etc.); (2) hemorrhage, subcranial, sub(hiral, or intracerebral; 
 (o) pro(hiets of iiiiiammatiou (serous cfrusion, lymph, pus); (4) 
 tumors of tlie brain; (o) accpiired internal hydrocephahis, etc. 
 
 Symptoms. — ^'ery sK)wly induced compression ma\' not produce 
 symptoms for a h)ng period; and even in cases of rapid compression 
 tliere often is' a ".s7ar/r of conipni.'iation'' from rise in blood-pressure, 
 during which no symptoms may be observed. During the sfaf/r of 
 manifest comprcfision two periods may be recognized: (1) Karly 
 sipnpioms: There is irritation of the cortical and medullary centres, 
 due to venous stagnation; slight quickening of respiration, and rise 
 in blood-pressure; headache, dizziness, restlessness, roaring in the 
 ears, disturbed sleep; moaning and groaning; and at times delirium. 
 Sometimes circulatory changes in the fundus oculi can be detected, 
 but these disappear in a few hours. (2) Late symptoms: The gradual 
 increase in the compressing force finally overcomes the blood-pressure, 
 and cerebral anemia results. This stimulates the vasomotor centre 
 which raises blood-pressure yet higher by causing peripheral capillary 
 constriction, especially in the splanchnic area. The patient lies 
 somnolent, stuporous, even comatose; with slow, full, bounding 
 pulse; there is labored respiration, which in the last stages approaches 
 the Cheyne-Stokes type; the cheeks are passively puflFed out at each 
 expiration ("smoking his pipe," the French call it); the pupils react 
 sluggishly or not at all. The more dilated pupil usually is on the side 
 of greatest compression. Sometimes the patient can be partially 
 roused from his coma by pressure on the supra-orbital nerve; then 
 slight convulsive movements of the extremities may occur, and hemi- 
 plegia, or localized paralysis may become evident. Irregularity of 
 the respiration is one of the earliest and surest signs of approaching 
 exhaustion of the medullary centres; and unless blood-pressure can 
 be measured periodically by the manometer, respiration is a more 
 reliable guide as to prognosis than the quality of the pulse; for the 
 "vagus pulse," slow% regular, and strong, continues practically 
 unchanged until very near the fatal ending. 
 
 Diagnosis, — If the early symptoms of the stage of manifest com- 
 pression were borne in mind, the condition often could be diagnosed 
 and measures for relief instituted, before the later stage, complicated 
 by unconsciousness, is reached. When an unconscious patient is 
 examined, the existence of an adequate cause for cerebral compres- 
 sion always should be excluded before dismissing this as the cause 
 of the symptoms. ]\Iany a patient suffering from cerebral compression 
 has been sent awa}' from accident wards as "drunk," when a very 
 little time spent in examination would have detected focal symptoms 
 (pupillary, facial, or lingual paralysis; monoplegia, hemiplegia, etc.); 
 while bulbar symptoms probably could have been discovered if they 
 had been specifically looked for. In any case of doubt, keep the 
 
574 SURGERY OF THE HEAD 
 
 patient under observation; if the cause of symptoms is compression, 
 this soon will become evident. 
 
 Prognosis.^ — This depends very largely upon the cause of the com- 
 pression, and the time at which treatment is instituted. In many 
 cases of brain tumor, for instance, it may be impossible to remove 
 the cause of compression, so that cure is out of the question; but 
 symptoms may be relieved and life prolonged by removing the counter- 
 pressure caused by the skull. But even in cases where the cause of 
 compression can be removed, treatment may not be instituted until 
 the last stages of compression, and the medullary centres may not 
 recover; or even though they recover, the focal compression may have 
 done so much damage to the cerebrum as to impair the patient's 
 mental or physical ability throughout life. 
 
 Treatment. — From what has been said above it is very evident 
 that the two main indications are to maintain blood-pressure at a 
 higher point than intracranial (extravascular) pressure, and to relieve 
 the compression by surgical means. The full, bounding pulse, the 
 singing in the ears, etc., of the early stages, do not by any means 
 indicate that the patient should be bled, or that aconite should be 
 administered; they are an index of his compensatory powers and 
 all that will save his life is to keep his blood-pressure high, and to 
 relieve the intracranial pressure as quickly as possible. Theoretically 
 the latter point may be gained by lumbar puncture of the subdural 
 space of the cord; but draining away cerebrospinal fluid, by removing 
 the brain's support from below, may serve only to allow the super- 
 incumbent pressure to force the medulla down into the foramen 
 magnum, thus strangulating it and causing instant death. The most 
 imperative indication is to "decompress" the brain by removing 
 some of the overlying cranium, on one or both sides. This may be 
 done by the trephine, the opening being enlarged by rongeur forceps, 
 or a bone-flap may be raised (p. 586). At the same time that decom- 
 pression is done, the cause of compression, whenever possible, should 
 be removed. The site of the cranial opening depends on the cause 
 of compression and on the existence of focal symptoms; when not 
 contraindicated the subtemporal operation of Gushing (p. 590) is 
 very satisfactory. 
 
 In the most advanced stages of cerebral compression emergency 
 measures are necessary to raise the blood-pressure until operation 
 can be undertaken; these are such methods as artificial respiration, 
 lowering the patient's head, bandaging his extremities, compression 
 of the abdomen, and the administration of strychnin, adrenalin, etc. 
 After decompression it should be remembered that the stimulating 
 effect of recurring anemia upon the vasomotor centre is lost; and 
 if this centre shows signs of exhaustion, it must be stimulated by 
 str.ychnin, or repeated doses of adrenalin. 
 
 Subcranial or Extradural Hemorrhage may be due to bleeding 
 from the diploe or cranial sinuses, in cases of fracture of the skull, 
 but in the vast majority of cases it is due to rupture of the middle 
 
COMI'lil'JSSION OF TIll'J lih'AIN 
 
 i^ti^ 
 
 incniiiiijciil artery. Middle iiirn'ni(i<'(d IwiiiorrlKuje may occur with or 
 without fracture of the skull, aud upou the side of iujury or ou the 
 opi)osite side (from "contre-coup"). The anterior l)raneh of the 
 artery is most often ruptureci, usually near the pterion, where it 
 passes throujjjh a bony f^roove or canal; but it may be torn off at its 
 exit from the foramen spinosum (by 
 concussion, or by a burstinjj; frac- 
 ture), or lacerated by bone fragments 
 at other i)arts of its course. The 
 bleeding which results slowly sepa- 
 rates the dura from the cranium, and 
 the resulting clot may spread over 
 an entire hemisphere (Fig. ()2()). 
 
 Diagnosis. — The usual history is 
 that after an injury to the head 
 the patient experiences momentary 
 symptoms of concussion, then re- 
 covers more or less completely ; but 
 some hours or even days later signs 
 of compression appear, sometimes 
 gradually, sometimes with alarming 
 suddenness. What is particularly 
 characteristic is the so-called "free 
 interval," between the injury, 
 when rupture occurs, and the 
 time when the accumulating clot 
 brings on symptoms of compres- 
 sion. 
 
 Treatment. — The treatment consists in exposing the main trunk 
 or anterior branch of the artery, removing the clot, tracing the bleed- 
 ing to its source, and ligating the artery by passing a fine suture 
 around it by means of a round-pointed needle. T. R. Neilson (11)03) 
 plugged the foramen spinosum wdth a match-stick. If the hemorrhage 
 does not come from the anterior branch, the posterior should be 
 exposed. If all focal signs are absent, and no cause for compression 
 is found on the side of the skull first opened, it is justifiable to open 
 the other side, as rupture may occur from counter-stroke. 
 
 Intradural Hemorrhage. — Bleeding into the meshes of the pia- 
 arachnoid, which is much more frequent than the extradural form, 
 almost invariably is of traumatic origin, venous in character, and 
 complicated by extensive cranial and cerebral injury (Fig. 021). 
 Usually the blood is widely diffused, and the fluid removed by lumbar 
 puncture may be blood-tinged. The symj)to7ns are those of cerebral 
 compression; "it is safe to say," writes Gushing, "that in anj^ serious 
 cranial injury in which unconsciousness has been present from the 
 first, subdural bleeding is taking place, either from the fracture 
 itself or from some laceration of the brain." Treatment consists in 
 decompression if symptoms of compression continue for more than a 
 
 Fig. 020. — Subcranial hemorrhage 
 from rupture of the posterior branch of 
 the middle meningeal artery. No frac- 
 ture of the cranium. Man, aged fifty- 
 one years, was found lying on the street, 
 unconscious. Taken to police station. 
 Operation about forty hours after in- 
 jury. Blood-pressure fell from 170 
 mm. before operation to 110 mm. a few 
 hours later. Recovery. Episcopal Hos- 
 pital. 
 
576 SURGERY OF THE HEAD 
 
 few hours or are well marked at first. Seldom is it possible to find 
 any distinct bleeding point, but exposure to the air, or gentle irriga- 
 tion with very hot saline, may be sufficient to arrest the hemorrhage. 
 Drainage is provided by strips of rubber tissue. The operation, 
 unless another opening is indicated by focal symptoms, should be 
 by Cushing's subtemporal route (p. 590) which gives ready access 
 to the base of the brain whence the bleeding usually arises. As 
 already mentioned (p. 566), Nassau tampons the subdural tissues 
 for four days, then replaces the dural flap. 
 
 Fig. 621. — Intradural hemorrhage. A boy of five years had a large flap of scalp torn 
 loose. Parietal bone bent inward, but no fracture. Operation three hours later (for 
 continued unconsciousness and left hemiplegia) showed extensive intradural hemor- 
 rhage, the brain being 4 cm. distant from the dura. After removal of compression respira- 
 tion improved, but death occurred in a few hours. Episcopal Hospital. 
 
 Intracranial Hemorrhages in the Newborn. — These occur usually 
 from a rupture of a vein in the pia-arachnoid, near the longitudinal 
 sinus, as the result of trauma during birth. The diagnosis is not 
 always easy, at least until signs of compression of the brain appear; 
 lumbar puncture may show bloody cerebrospinal fluid; and cerebral 
 irritability and irregularity of respiration are suggestive. The prog- 
 nosis is bad; nearly 80 per cent, die from cerebral compression within 
 a few days; while of those that recover most are mentally deficient 
 or afflicted with spastic paralysis (p. 530), athetosis, nystagmus, 
 etc. Treatment: Operative relief, proposed by Keen in 1901, was 
 first employed in 1904 by Cushing, who has reported (1908) nine 
 operations, with four recoveries. A large osteoplastic flap, which 
 can be cut out with strong scissors, is raised, the dura is opened, the 
 clots removed by gentle irrigation, and the wound closed without 
 drainage. 
 
 Intracerebral Hemorrhage occurs chiefly as the result of vascular 
 disease (ordinary "apoplexy"), or from degenerative changes in 
 brain tumors. Wounds are occasionally causes of localized cortical 
 hemorrhage. The suggestion by Leonard Hill (1896) that surgery 
 by effecting decompression, or even by evacuation of the clot, might 
 be of use in these cases, was acted upon with success by Borsuk and 
 
SIMS riiiioMiiosis :ui 
 
 Wizel (I.S97) ill ;i tr;iiiniatic case, ("iisliiiij; (1!)()S) lias ((pcratcd on 
 four cases oF spontaneous lieniorrha^c, one operation (suhtcuiporai 
 decompression and e\acuation ot" tlie clot) heinj^ successful. I'lider 
 expectant treatment the mortality is nearl.x 00 per cent., in these 
 cases of acute severe apoplexy, in which alone is operation to be 
 considered. 
 
 Sinus Thrombosis. This arises, in the vast majority of cases, by 
 extension of .septic iuHammation from the air sinuses of the skull, 
 especially tlie mastoid cells. Pyoffcnic inflammation of the scalp or 
 erysipelas are rare cau.ses, the infection spreading along the diploic 
 emissary veins. The (licifino.sis depends on reco<;nizinff a focus from 
 which sei)tic inflannnation may be derived, on local sij^ns such as 
 edema of the overlyinj; scalp, and distention of its veins, together 
 with evidences of constitutional sepsis, and perhaps cerebral com- 
 pression. The longitudinal sinns may be thrombosed from frontal, 
 ethmoidal, or si)hen(Mdal sinusitis, or rarely from erysipelas of the 
 scalp, etc. Thrombosis of the cavernovs sinus, which is very rare, 
 may arise from extension of inflammation along the facial and angular 
 veins (carbuncle of upper lip, etc.), or along the petrosal sinuses 
 (from the sigmoid sinus), and is particularly characterized by the 
 resulting exophthalmos. 
 
 The lateral sinus, especially its sigmoid portion, is that which is 
 involved in by far the largest number of cases, and almost always 
 as the result of middle-ear disease, the infection coming along the 
 emissary veins or directly invading the sinus wall after destruction 
 of the intervening bone. The symptoms are those of the preexisting 
 disease (mastoiditis), of sepsis (repeated chills, sweating, hectic 
 temperature), and cerebral irritation or compression (rare); but 
 such symptoms often do not appear until the sinus thrombosis has 
 been in existence for some days, and may indicate a softening of the 
 clot and dissemination of emboli. Naturally the lungs are most 
 often attacked in this way. Thrombosis is prone to extend to the 
 internal jugular vein, and often this can be felt as a tender cord in the 
 neck. The head may be tilted to the affected side. In meningitis, 
 which is much commoner in infants than adults as a result of middle- 
 ear disease, cerebral symptoms (vertigo, vomiting, hebetude, delirium) 
 are more marked, there is retraction of the neck and paralysis of the 
 ocular muscles, with choked disk; fever is higher and more regular; 
 Kernig's sign is present; and lumbar puncture shows turbid cerebro- 
 spinal fluid, from which organisms may be recovered. In brain 
 ab.scess cerebral symptoms, without those of meningitis, predominate; 
 temperature is subnormal; there is evidence of cerebral compression; 
 and emaciation is rapid. In neither meningitis nor in uncomplicated 
 cases of brain abscess is there thrombosis of the internal jugular vein. 
 
 Treatment. — The first step is to clear out the mastoid, and this 
 merely preliminary measure should not be done with too great delib- 
 eration (see Chapter XIX). The shell of bone which overlies the 
 sigmoid sinus is then removed by gouge or burr, and the sinus well 
 37 
 
578 SURGERY OF THE HEAD 
 
 exposed; plenty of room should be gained by use of the rongeur. The 
 sinus is next incised: if bleeding occurs the sinus is compressed first 
 on the torcular side; and, if it continues, also on the jugular side of 
 the incision. Persistence in bleeding, when pressure is made at both 
 these points, indicates a return flow from the mastoid emissary or 
 superior petrosal sinus. These should be separately tested. If the 
 petrosal is not thrombosed it is probable that the entire system is 
 healthy. 7/ no bleeding occurs when the sinus is opened, it should 
 be slit up toward the torcula until a return flow is obtained; this is 
 controlled by packing; the clot is then removed as far as the original 
 incision, and, after temporary pressure has been made on both jugulars 
 in the neck, a similar procedure is carried out at the bulbar end of the 
 sinus. If no return flow can be obtained from this end of the sinus, 
 it is a sign that the thrombus extends into the jugular, and resection 
 of this vein should be done. It is to be performed as a primary oper- 
 ation, before exposing the sinus, when a diagnosis of jugular thrombosis 
 is made in advance. Resection of the Internal Jugular Vein: The 
 vein is exposed and doubly ligated low in the neck; it is divided 
 between these ligatures and dissected upward, clamping and tying 
 each branch encountered. Thrombosed branches should be excised. 
 When the vein has been traced up as far as possible, it is ligated and 
 cut across. The neck wound is tamponed with gauze and not closely 
 sutured. If the jugular vein is too densely adherent to be removed 
 safely, it should be slit open, and the wound packed with gauze. 
 The general mortality of thrombosis of the lateral sinus is about 25 
 per cent. 
 
 Meningitis. — External Pachymeningitis, usuall.y purulent and local- 
 ized (subcranial abscess), affects the external layer of the dura, and 
 may result from osteomyelitis of the cranium (p. 566) with or 
 without fracture of the skull, or from neighboring sinus thrombosis. 
 Treatment consists in removal of the overlying bone, with drainage. 
 
 Internal Pachymeningitis is a rare disease, of subacute or chronic 
 character, in which membranous lymph, easily detachable, is deposited 
 on the inner layer of the dura. It is microbic in origin, occurs some- 
 times in general infections (typhoid fever, pneumonia), and some- 
 times is hemorrhagic in type. The symptoms are not very character- 
 istic, being those of slowly increasing cerebral irritation or compres- 
 sion; and the diagnosis is difficult. Treatment: operation, comprising 
 removal of the false membrane or hemorrhagic exudate, offers the 
 only hope of cure or prevention of insanity (Munro, 1902). 
 
 Leptomeningitis. — Inflammation affecting the pia-arachnoid may 
 be due to a number of bacteria; the form known as epidemic cerebro- 
 spinal meningitis, caused by the Diplococcus intracellularis, is a 
 specific contagious disease, usually coming under the physician's 
 care. Early use of Flexner's serum (1906) is most important. As 
 the ultimate cause of death is purely mechanical, being due to cerebral 
 compression from acute internal hydrocephalus (p. 554), surgical 
 treatment may be advisable when purely medical measures have 
 
BRAIN ABSCESS 579 
 
 failed. Lumbar puucturo, used for diagnosis, is of no therapeutic 
 value wlien liytlroceplialus supervenes; the only remedy is single or 
 rej)eated puncture of the ventricles. 
 
 Leptomeningitis also may be caused by ordinary pyogenic cocci, 
 pneumococcus, B. tuberculosis, etc. P^specially in tiibrrciiloKS inenin- 
 gitis, which is so uniformly fatal under medical treatment, it seems 
 as if almost any surgical risk were justifiable. Lumbar puncture 
 will relieve the intracranial tension, due to accumulation of sero- 
 purulent exudate, so long as the medulla is not driven down like a 
 cork into the foramen magnum, or so long as the foramina in the 
 roof of the fourth ventricle are patulous (p. 554). But when acute 
 internal hydrocephalus develops, the only hope of relief lies in 
 tapping the ventricles (p. 555) or their permanent drainage into the 
 subdural space (p. 55(i). 
 
 Serous or Amicrobic Meningitis is a form of the aflection in which 
 clear, sterile serous fluid collects in the intradural spaces (Eichhorst, 
 1887). Some cases are traumatic in origin, but most are regarded 
 as due to bacterial infection localized elsewhere in the body, thus 
 being analogous, as pointed out by Archibald (1908), to the sterile 
 serous effusion of pleurisy secondary to subphrenic abscess. Some- 
 times this affection complicates sinus thrombosis or mastoiditis. 
 
 Diagnosi,s. — The diagnosis is difficult, the serous character of the 
 effusion being discovered first at operation undertaken to relieve 
 pressure symptoms thought to be due to subcranial or intradural 
 suppuration, or to brain abscess. 
 
 Treatment. — In traumatic cases lumbar puncture may suffice to 
 evacuate the fluid; in others craniotomy should be done. If serous 
 meningitis is found, undue persistence should not be exercised in 
 searching for a brain abscess which may not exist. 
 
 Syphilis of the Leptomeninges. — Practically all the intracranial 
 lesions of syphilis arise in the meninges and involve the brain only 
 secondarily, by pressure. They are found most often in the arachnoid 
 tissues, especially in the frontal region and at the base. The diagnosis 
 from cerebral tumors is not easy, but the treatment is much the 
 same (p. 585). 
 
 Encephalitis or Cerebritis, except as it complicates traumatic 
 lesions, concerns surgeons little, unless in localized form (Brain 
 Abscess). There is supposed to be an epidemic form, analogous to 
 acute anterior poliomyelitis, of which, probably, more will soon be 
 heard. 
 
 Brain Abscess. — This is due in about equal proportions to tramna, 
 especially penetrating and punctured wounds, and to supimrative 
 disease of the mastoid cells, middle ear, or other air sinuses of the 
 cranium. It occurs also in pyemia, but very much less frequently. 
 The site of the abscess in the brain depends largely on the focus of 
 infection. Frontal abscess results from disease of the frontal sinuses, 
 ethmoid and sphenoid cells, cavernous sinus, thrombosis, etc. Middle- 
 ear disease is the chief cause of abscess in the temporo-sphenoidal 
 
5S(1 
 
 SURGERY OF THE HEM) 
 
 lobe; while cerebellar abscess usually is secondary to mastoid disease 
 or lateral sinus thrombosis. The causative condition frequently 
 has been in existence for months or even years, before brain abscess 
 develops. The cerebrum is affected more than twice as often as the 
 cerebellum. The abscess almost always is in the subcortical area 
 of the brain, and seldom has any macroscopical connection with the 
 
 Fig. 622.— Cerebral abscess from mid- 
 dle-ear disease; initial stage: headache, 
 nausea, chilliness, and fever. (G. 
 Laurens.) 
 
 Fig. 62.3. — Cerebral abscess from 
 middle-ear disease; manifest stage: per- 
 sistent headache, mental hebetude, and 
 other symptoms of compression. (G. 
 
 Laurens.) 
 
 source of infection, having arisen from embolism (rare), or by pro- 
 gressive thrombosis of minute venous channels. Usually, if not 
 invariably, however, there exi.sts a microscopic connection between 
 the source of infection in the cranial bones and the abscess cavity; 
 the abscess has been compared to a mushroom, growing by a stalk 
 from the neighboring carious bone. 
 
 Fn;. 624. — Cerebellar abscess from middle-ear disease, simulating meningitis 
 (retraction of the head, occipital headache, etc.). (G. Laurens.) 
 
 Symptoms. — AYhen the abscess follows middle-ear disease, which 
 is its most frequent single cause, and may be taken as the type, it is 
 usual for there to have been some recent exacerbation of the chronic 
 symptoms. The course of a typical case is well sketched by Cushing: 
 after the exacerbation of the old symptoms, arise those of the initial 
 stage of brain abscess (headache, nausea, chilliness, and fever) (Fig. 
 
BRAIN TVMOR oSl 
 
 022); these may subside, hut rarely disappear entirely, for a period iA 
 a week or ten days {latent stage) ; then, with more or less sudden cessa- 
 tion of diseharfje from the ear, symptoms of intracranial sepsis and 
 pressure become evident (i)ersistent headache, mental hebetude, vom- 
 iting, slow pulse, subnormal temperature, and leukocytosis (manifest 
 stagr) (Fig. (528). I'sually there are no distinct focal symptoms, other 
 than marked tenderness of the overlying skull, and sometimes facial 
 ])aralysis. Raj)id emaciation is a very significant sign. If the abscess 
 is in the cerebellum, meningitis may be simulated (Fig. (524). The 
 distinction between abscess and tumor of the brain seldom is difficult 
 
 (p. r)S:5). 
 
 Treatment. — The abscess must be drained as early as possible. 
 Do not delay overnight if you suspect an abscess. Some surgeons 
 prefer to do a tympano-mastoid exenteration first, and then wait a 
 few da}s, to see if the symptoms suggestive of brain abscess will 
 subside; but if an abscess is present, any delay is dangerous. IMany 
 operators prefer to open the intact cranium (Macewen, 1893) over 
 the supposed site of abscess, and to proceed to exenteration of the 
 tympano-mastoid only after evacuating the abscess. For abscess 
 in the temporu-sphenoidal lobe trephine at a point one inch above the 
 supra-meatal spine. The cerebellum is exposed by trephining below 
 the lateral sinus and posterior to its sigmoid portion. ]Most aurists 
 think it safer to approach the brain abscess through the middle 
 ear or mastoid, because by this avenue one is most certain to cross the 
 meninges where adhesions exist, and can follow on to the abscess 
 along its "stalk." ^Yhen the cortex is exposed, in either case, measures 
 should be taken to prevent contamination of the meninges, unless 
 the diseased area is isolated already by adhesions. The brain is 
 then explored by a grooved director, and when pus is found the 
 overlying cortex is incised on the director, sufficiently to secure 
 drainage. This is difficult to maintain, as the semifluid brain tends 
 to block the tube. Should damming up of pus be suspected the 
 wound must be reopened. Even in the hands of the most skilled 
 and expert surgeons, operation for brain abscess is attended by a 
 mortality of about 50 per cent.; but as all patients will die, and quite 
 as soon, if no operation is done, this should not deter one from trying 
 to save even moribund patients. 
 
 Brain Tumor. — Any growth within the cranium, whether a true 
 neoplasm or an infectious granuloma, is considered clinically a 
 "brain tumor," because productive of the same general signs. Tuber- 
 culoma is the most frequent growth in childhood; these tumors occur 
 with special frequency in the cerebellum, and often are multiple. 
 Syphiloma is more common in adults, being usually a meningeal 
 growth which compresses the brain secondarily. These two t}'pes 
 of growth from a larger class of brain tumors than do the true neo- 
 plasms. Of the latter, the most frequent are endothelioma and glioma. 
 The former grows from the meninges, usually is encapsulated and 
 easily enucleated from the cup-shaped depression it produces in the 
 
582 SURGERY OF THE HEAD 
 
 surface of the brain; the glioma, on the other hand, usually is an 
 infiltrating growth of the subcortical area, and is with difficulty 
 distinguishable macroscopically from normal brain tissue. Sarcoma, 
 which is less usual, grows from the connective tissue of the meninges, 
 frequently invading the bone; or may arise in the cortex, whence it 
 sometimes can be shelled out, owing to peripheral degenerative changes. 
 Often it is multiple, and is a more frequent form of metastatic growth 
 than carcinoma. Fibroma is seldom seen except in the cerebello- 
 pontine angle. Cysts occur in the brain; some are of parasitic origin 
 (echinococcus, cysticercus), others are the result of hemorrhages into 
 the brain substance, or arise as degenerative changes in a glioma. 
 The latter is the usual cause of cerebellar cysts. 
 
 Symptoms. — Tumors grow in the brain oftener than in any other 
 part of the body. Hale White (1885) estimated that a tumor is found 
 in the brain in one among every 59 autopsies. They may exist for 
 years and cause no symptoms, if in a silent region or if of very slow 
 growth. They occur mostly between the ages of fifteen and fifty. In 
 old age and infancy they are rare. It is usual to discuss the symp- 
 toms of brain tumor under two headings, general symptoms, and 
 localizing symptoms. 
 
 General Symptoms. — The syndrome of brain tumor comprises the 
 three cardinal symptoms, headache, vomiting, and papilledema. Headache 
 at first is intermittent, but when constant, and especially when referred 
 persistently to one region, which is tender to percussion or pressure, 
 must be regarded as highly significant; probably it is due, as pointed 
 out by Gushing (1908), to pressure upon or distortion of the falx 
 or tentorium, as the brain itself is insensitive. The vomiting, perhaps 
 due to irritation of the pneumogastric nerve, is projectile in character, 
 may occur independently of meals, and be unattended by nausea. 
 Papilledema, optic neuritis, or choked disk, is a characteristic change 
 in the eye-grounds, commonly believed to be due to damming up of 
 the cerebrospinal fluid in the sheath of the optic nerve, as the result 
 of increased intracranial tension. If this pressure is not relieved, 
 hemorrhages may occur in the nerve head and retina, resulting in 
 permanent blindness. Usually both optic nerves are affected, but 
 unequal involvement of the two nerves does not indicate that the 
 compressing lesion is on the side where papilledema is greatest, 
 unless only one nerve is appreciably involved. Papilledema often 
 is more marked in subtentorial lesions than others. The importance 
 of examining the eye-grounds in all suspected cases of intracranial 
 lesion cannot be too much emphasized, as acuity of vision may persist 
 even when papilledema is moderately far advanced. On the other 
 hand, this sign may be entirely absent throughout the course of the 
 disease. Gushing recently has called attention to changes in the 
 color fields, detected by expert ophthalmological examination, as 
 one of the earliest of the general signs of brain tumor. No bulbar 
 symptoms, such as occur in compression of the brain from trauma, 
 are observed in cases of brain tumor, because the increase in pressure 
 
BhWI.S TIMOR 583 
 
 is so very gradual. Occasionally a hraiii tumor, previously unsus- 
 pected, makes its presence known first by the occurrence of a hemor- 
 rhage into the tumor, the symptoms resembling those of ordinary 
 apoplexy; and in a young adult such an occurrence should rouse the 
 suspicion of a brain tumor. 
 
 Loralizinr/ Si/mptoms. — These are interpreted through anatomical 
 knowledge of the seat of the cerebral functions. As the increase in 
 pressure occurs very slowly, it is the rule for the development of paralytic 
 symptoms to be delayed, usually being preceded by irritative symptoms 
 (Jacksonian epilepsy, p. oDO); and a very slowly growing tumor in a 
 silent region of the brain may produce no localizing symptoms until 
 by encroachment it involves the nearest physiologically recognizable 
 centre, causing "neighborhood" as distinguished from true "focal" 
 symptoms. Thus a tumor in the frontal lobe may make its presence 
 known only by general symptoms (headache, vomiting, papilledema), 
 until so large as to interfere with the motor functions; and when 
 paralysis of motion at last occurs, the incautious observer may jump 
 to the conclusion that the tumor is growing in the motor region; 
 instead of recognizing the fact, as he would have done if an accurate 
 history of the progress of the disease had been obtained, that the 
 growth evidently was primary' elsewhere, and had compressed the 
 motor region only secondarily. 
 
 Diagnosis. — This involves not only the determination whether a 
 tumor exi-sts at all, but also the recognition of the kind of tumor 
 present, and its location. 
 
 1. Brain tumor may be closely simulated by the cerebral symptoms 
 of chronic nephritis; the urinary changes in the latter condition are 
 the chief distinction, but as a brain tumor may coexist, the patient 
 should be watched for the development of localizing symptoms. 
 Abscess of the brain usually may be distinguished from brain tumor 
 by the history of trauma, bone disease, etc., which is absent in the 
 latter affection; as well as by the more acute course of the disease 
 in cases of brain abscess. Acquired internal hydrocephalus (p. 554) 
 is to be distinguished by the usual bilateral distribution of any local- 
 izing signs. Sometimes a brain tumor may be detected by aid of a 
 skiagraph. 
 
 2. llie kind of tumor is very difficult and usually impossible to 
 determine. The existence elsewhere in the body of a tuberculous 
 process naturally would suggest a tuberculoma as the cause of the 
 cranial symptoms; as would a history of syphilis or evidence of past 
 or present S3'philitic lesions the existence of a syphiloma. The tuber- 
 culin tests and the Wasserman reaction are also available. The use 
 of antisyphilitic remedies, as a method of exclusion, though quite 
 habitual, should not be persisted in for more than six weeks (Horsley, 
 1890), unless relief of symptoms is secured sooner; because, in the 
 first place, few intracranial syphilomas are permanently influenced 
 by medication, and, secondly, other forms of tumor ma}^ undergo 
 temporary regression under antisyphilitic treatment, only to cause 
 
584 SURGERY OF THE HEAD 
 
 renewed symptoms later. Moreover, it is quite characteristic of 
 the intracranial lesions of syphilis to undergo spontaneous retro- 
 gression and recrudescence, even in the absence of treatment. Lumbar 
 puncture may aid the diagnosis by showing the constant lymphocy- 
 tosis so characteristic of syphilis, or by revealing the tuberculous 
 nature of the affection by appropriate pathological methods. Noth- 
 ing certain can be said of the diagnosis of glioma, endothelioma, 
 sarcoma, etc. 
 
 3. The Site of the Tumor. — If in the frontal lobe no localizing symp- 
 toms will be recognized, but there may be certain alterations in 
 intellect appreciable by the patient's family or intimates. P>ontal 
 lobe tumors often are found at autopsy on the insane. A certain 
 degree of incoordination may be present, affecting the equilibrium 
 in standing or walking, and causing resemblance to cerebellar tumors. 
 A tumor in the motor area (anterior to the Rolandic fissure) will 
 produce first Jacksonian epilepsy (p. 590), and later motor paralysis 
 of the opposite side, first of the centres nearest the growth, and later 
 of the entire motor cortex of the hemisphere involved. In the parietal 
 lobe (just posterior to the fissure of Rolando) sensory disturbances 
 (such as loss of muscle sense, posture sense, etc., or word blindness) 
 will precede Jacksonian fits and loss of motion, which latter phenomena 
 will result when the tumor reaches such a size as to press upon the 
 cortex or subcortical fibres in front of the fissure of Rolando. A 
 tumor in the superior parietal convolution may cause astereognosis. 
 A tumor of the occipital lobe, or posterior part of the parietal lobe, 
 should be suspected if vision is affected early (homonymous hemi- 
 anopsia, sometimes preceded by visual hallucinations, such as flashes 
 of light, seeing objects upside down, etc.). Tumors in the temporo- 
 sphenoidal lobe give rise to deafness, loss of taste and smell, and the 
 convulsions which occur often are preceded by a sensory aura. Tumors 
 at the base of the brain are particularly characterized by paralysis of 
 the difi'erent cranial nerves, as well as by hemiplegia, hemianesthesia, 
 etc. Tumors of the hypophysis cerebri may produce symptoms of 
 hyperpituitarism (gigantism in infants, acromegaly in adults) or of 
 hypopituitarism (adiposity, with infantilism in children, and loss 
 of sexual characteristics in adults), according as the anterior or 
 posterior portions of the hypophysis are involved; in either case, 
 the general symptoms of brain tumor are present, together with 
 bitemporal hemianopsia from pressure on the optic chiasm. A good 
 skiagrai)h may demonstrate increase in size of the sella turcica. 
 Subtentorial tvviors may be within the cerebellum or may grow from 
 the meninges. The general symptoms occur early, and are constant 
 and severe; and in addition to the cardinal symptoms of brain tumor 
 already mentioned, these subtentorial growths are characterized 
 esjjecially by vertigo, cerebellar ataxia, nystagmus, etc. Most 
 symptoms occur on the same side as the lesion. Of the extracere- 
 bellar tumors those growling in the cerebeUoyontine angle are most 
 frequent; usually they are fibromas, growing from the sheath of the 
 
BRAIN TUMOR 
 
 585 
 
 ci^litli (Tiuiial nerve, and cause persistent tiiniitus aurinni, and d<>af- 
 ness ot" th • same side; while at a later stage they cause paralysis ol' the 
 fifth, sixth, and seventh nerves, and may finally simulate tumors 
 within the cerehellum (Fig. ()25). They are lightly attached by a 
 small pedicle, and usually can be enucleated easily. JntracereheUar 
 iumors are characterized l)y the early development of vertigo, changes 
 in the eye-grounds (sometimes blindness Ix'fore ])a{)illedema). and 
 sensations of motion of self or of surround- 
 ing objects; the head is tilted, usually 
 toward the side of the lesion, and there 
 is staggering gait, with tendency to fall 
 constantly in one direction, often toward 
 the side of the lesion. The ataxia is not 
 increased by shutting the eyes. It is more 
 marked in tumors of the vermis than 
 in those of the hemispheres. Tumors of 
 the yons and medulla are rapidly fatal, are 
 not amenable to operative treatment, and 
 often camiot be distinguished from cere- 
 bellar growths. 
 
 Treatment. — An untreated brain tumor 
 uniformly leads to death. Purely medical 
 treatment is inefi'ective even in controlling 
 the most distressing symptoms, pain and 
 blindness. Operation, merely by remov- 
 ing the overlying cranium and thus reliev- 
 ing the brain of pressure {decovii^ession) 
 may cause disappearance of all symptoms 
 for an indefinite period, even restoring 
 sight; and in some cases the tumor can 
 be removed, effectually curing the patient. 
 A radical operation, including removal of 
 
 the tumor, of course, always is to be preferred; but when an unlocalized 
 tumor exists, making its presence known only by the "syndrome of 
 brain tumor," the surgeon should not hesitate to relieve the headache, 
 check the vomiting, and prevent the development of blindness or 
 possibly to restore sight which has failed, by means of the palliative 
 operation. This operation also is employed when a tumor is found 
 which cannot be removed, either because of its situation, its size, or 
 its infiltrating character. 
 
 A tumor in one of the cerebral hemispheres is exposed by the forma- 
 tion of a bone-flap (the so-called osteoplastic craniotomy, p. 580), 
 the bone being replaced after the removal of the tumor. If no tumor 
 is found, or if it cannot be removed safely, the bone is removed from 
 the flap, thus converting the operation into one of decompression. 
 Indeed, Horsley never replaces the bone-flap even after the tumor has 
 been successfully removed. But where decompression is planned 
 in ach'ance, the subtemporal operation of Cushing is to be preferred 
 
 Fig. 625. — Tumor in right 
 cerebollo-pontine angle. Age 
 forty-nine years. Symptoms 
 began two or three years ago; 
 worse for last six to eight 
 months, since which time there 
 have developed ataxia, deaf- 
 ness, facial paralysis, and loss 
 of eyesight. (Paralysis of sixth, 
 seventh, eighth nerves, paresis 
 of ninth, and double choked 
 disk.) (Dr. F. W. Sinkler's 
 patient.) Orthopaedic Hospital. 
 
586 sunaERY of the head 
 
 (p. 590). A tumor beneath the tentorium is exposed by removal of 
 bone from one or both occipital fossa?; and the bone is not replaced. 
 A tumor of the hypophysis grows either toward the brain, or toward 
 the vault of the pharynx; this usually may be determined by skiagraphy. 
 If the tumor appears accessible from within the cranium, it is 
 best approached across the anterior fossa of the skull, by means of a 
 frontal bone-flap, according to Frazier's modification of McArthur's 
 method (1912): a large bone-flap with external base is elevated from 
 the right frontal region, and the supra-orbital margin and roof of 
 the orbit are temporarily resected. The dura covering the frontal 
 lobe is then elevated from the base of the anterior fossa, and is incised 
 directly over the pituitary body. The sella turcica may also be 
 approached by the lateral route, elevating the temporal lobe from 
 the base of the skull after removal of nearly the entire side of the 
 calvaria (Horsley) ; or by the naso-frontal route of Giordano, employed 
 by Schloffer (1907), and von Eiselsberg (1910); or by the m/ra-na^a/ 
 method of Kanavel (1909), employed by Halstead (1910) and by 
 Mixter (1910). In Halstead 's operations a preliminary tracheotomy 
 was done, and the pharynx was tamponed. Raising the upper lip, 
 an incision is made through the mucous membrane of the superior 
 alveolus, and the cartilaginous septum of the nose is divided. The 
 nose is then retracted upward. After the bony septum and turbinates 
 have been excised, the anterior wall of the sphenoidal sinus is 
 exposed at the bottom of the wound. This wall being broken 
 through, the posterior wall is identified. This lies at a distance of 
 from 70 to 83 mm. from the anterior nasal spine, and often is thinned 
 by the growth of the tumor within the sella turcica. As soon as the 
 latter cavity is opened, the tumor tissue, which usually is fluid, is 
 evacuated and the cavity is lightly curetted. The tumor cavity and 
 the entire wound are then packed with iodoform gauze, which emerges 
 through the nostrils; the nose is replaced and retained by a suture 
 or two, and finally the alveolar mucous membrane is sutured. 
 
 Osteoplastic Craniotomy, or Temporary Resection of the Skull for 
 Brain Tumor. — The strictest aseptic technique is requisite. Hemor- 
 rhage from the scalp may be controlled by an elastic band passed 
 around the occipito-frontal circumference of the head. The "head- 
 high" position lessens venous congestion. A skin-flap is outlined 
 with a narrow base in the temporal region, the flap being so situated 
 as to overlie the supposed site of the tumor. The tissues of the scalp 
 are not separated from the underlying bone, which is cut through in 
 the same lines as the skin incision. Various methods are employed 
 for dividing the bone: Frazier makes a trephine opening at each side 
 of the base of the flap, and cuts the margins of the bone-flap by 
 Cryer's spiral osteotome (1897), which is a side-cutting rotatory 
 fraise, propelled by a dental engine (Fig. 626) ; Gushing drills holes in 
 the bone at the four corners of the bone-flap, and divides the bone 
 along the top and each side of the quadrangular flap by means of the 
 Gigli wire saw (1897), which cuts from within outward (Fig. 627); 
 
OSTEOPLASTIC CRANIOTOMY 
 
 587 
 
 Fig. 626. — Cutting the bone-flap by 
 means of Oyer's spiral osteotome. 
 
 Fig. 627. — Cutting the bone-flap by means of 
 the Gigli wire saw. (See Fig. 4.S6.) 
 
 Fig. 628. — Instruments used in making an osteoplastic flap of the skull: 1. Pe 
 Vilbiss's forceps; 2, mosquito hcmostat; 3, ordinary hemostat; 4, Hudson's trephine 
 (see p. 563), with four bits: 5, the perforator; 6, 7, 8, burrs to enlarge the original 
 perforation. (See Fig. 629.) 
 
588 
 
 SURGERY OF THE HEAD 
 
 others use a bone cutting forceps, like a very narrow rongeur, which 
 nips out a channel of bone around the margin of the bone-flap (Fig. 
 628); some surgeons use a mallet and chisel, or a circular saw run by 
 a dental engine. The easiest way to drill the holes is by means of 
 Hudson's trephine (Fig. ()29). In any case, after the top and two 
 sides of the bone-flap have been cut through, its narrow base 
 (composed of the thin bone of the temporal fossa) is fractured by 
 prying up the bone-flap by two bone elevators (Fig. 614, 3). Bleeding 
 from the diploe is controlled by application of minute slips of muscle 
 tissue (cut from the temporal muscle) or by plugging with Horsley's 
 wax. Archibald uses the original preparation: beeswax, 7 parts; almond 
 oil, 1 part; salicylic acid, 1 part. Hartley preferred this formula: 
 vaselin, 50 parts; paraffin, 50 parts; phenyl, 5 parts. Some surgeons 
 
 Fig. 629. — Hudson's trephine in use. 
 
 prefer to do this operation in two stages, replacing the bone-flap and 
 postponing exploration for the tumor until some days later; but 
 unless unexpected difficulty or delay has attended the formation of 
 the bone-flap, it is better to conclude the operation in one sitting.^ 
 
 The dura, being thus exposed over a wide area, is incised concentric- 
 ally with the bone, leaving a sufficient margin to facilitate closing 
 it again by suture. When the cerebral cortex is exposed, the tumor 
 may be found on its surface; it then usually is lightly attached, and 
 
 1 dishing has found that the second stage of such an operation may be con- 
 ducted without the use of any anesthetic, except "primary anesthesia" for suturing 
 the skin-flap at the end of the operation, since the dura and cortex are totally 
 insensitive to gentle manipulation. 
 
DFA'OMI'UKSSIVI-: (U'Mh'ATlOX I'OU liUMX TCMOR 
 
 :).S!) 
 
 may he (Miiiclcatcd. If no tumor is visible, it is jiistifiahic to explore 
 the suheortical region. It is extremely important to control liemor- 
 riiage from the pial vessels; any bleeding points should be caught 
 in mosquito hemostats (Fig. ()2S) and ligated or sutured with very 
 fine silk. Sometimes it is sufficient to apply mimite slips of muscle 
 tissue. To explore the subcortical region an incision with scalpel is 
 made in lhe middle of a convolution free of vessels, and if an encap- 
 sulated tumor is found it is shelled out by blunt dissection; a cyst 
 should be evacuated and its lining wall removed if this is possible 
 without trauma. A diffusely infiltrating growth should not be 
 removed. I have seen a surgeon scoop out spoonful after spoonful 
 of tissue from one cerebral hemisphere which was pronounced by 
 several distinguished neurologists who were present to be typically 
 gliomatous in appearance; yet microscopical study j)roved the tissue 
 removed to l)e normal cerebral substance, while at autopsy the tumor 
 was found in a totally different part of the brain. Hemorrhage from 
 the brain substance is controlled by extremely gentle irrigation 
 with hot (115° to 120° F.) saline solution, or by light pressure with 
 pledgets of dry absorbent cotton, or the application of muscle tissue. 
 The dural flap is then sutured as accurately as possible ; the bone-flap 
 is replaced, and the skin is sutured tightly with closely set interrupted 
 sutures of silkworm gut, which control all bleeding from the scalp. 
 Never hurry, and use only extremely gentle manipulations in brain 
 surgery. Keep the wound free from blood, and avoid drainage 
 whenever possible. 
 
 
 H ^B 
 
 
 *^" 3 
 
 
 M^'* ^1 
 
 
 ^■-^y 
 
 Fig. 630. — Cicatrix of operation by 
 osteoplastic flap, for middle meningeal 
 hemorrhage. Age fourteen years. (Dr. 
 Frazier's case.) Episcopal Ho.spital. 
 
 Fig. 631. — Hernia cerebri three 
 months after operation for cerebral 
 tumor. (Dr. W. .J. Taylor's case.) 
 Orthopaedic Hospital. 
 
 Decompressive Operation for Brain Tumor.— As stated already, 
 an osteoplastic craniotomy may be converted into a decompressive 
 operation by removal of bone from the flap, replacing only the tissues 
 
590 SURGERY OF THE HEAD 
 
 of the scalp. The ckiral flap which has been turned down for the 
 purpose of exploration, is replaced but is not sutured, and the brain 
 bulges into the opening, relieving the intracranial pressure, and is 
 covered only by the tightly sutured scalp. Such a i)rotrusion, known 
 as hernia cerebri, may be very unsightly (Fig. 631), and as the tumor 
 continues to grow the hernia may become immense, and may cause 
 sloughing of the overlying scalp, with secondary infection of the 
 cerebral substance. A better operation, when decompression is 
 planned in advance, is the subtemporal decompressive operation of 
 Gushing: in this a flap of skin is turned down over the temporal 
 fossa, exposing the temporal muscle covered by its aponeurosis; 
 these structures are then divided down to the bone in a straight 
 line parallel to the muscular fibres, from temporal ridge to zygoma; 
 by retracting the muscle a fairly large area of cranium is exposed; 
 this is trephined, and the opening is enlarged by rongeur forceps 
 and the dura is incised around the margin of the skull opening. The 
 muscle and the skin-flap are then sutured, without drainage. The 
 hernia cerebri, which results, protrudes beneath the temporal muscle, 
 which acts as support, rendering the deformity much less conspicuous. 
 Frazier employs a similar decompressive operation on the occipital 
 bone, in cases of inoperable cerebellar tumors. It may be impossible 
 to close the scalp, in some cases of inoperable brain tumor, after de- 
 compression has been accomplished, owing to the protrusion of the 
 hernia cerebri ; but if necessary this may be diminished by elevating 
 the patient's head, or even by lumbar or ventricular puncture. 
 
 Patients may live for months or years after a decompressive opera- 
 tion, being symptomatically relieved until rapid death results from 
 some incurable complication. 
 
 Fungus Cerebri should be distinguished from hernia cerebri, 
 mentioned above. The former is an old term which it is convenient 
 to retain to describe granulations ("proud flesh") springing from 
 cerebral substance exposed in a wound, and developing as the result 
 of infection. Fungus cerebri may occur in cases of compound frac- 
 ture, with rupture of the dura and protrusion of brain substance; 
 or in cases of hernia cerebri secondarily infected from sloughing of 
 the overlying scalp. The treatment consists in antiseptic and astrin- 
 gent applications, of which alcohol is the most efi^ective. This grad- 
 ually causes the granulations to shrivel up. If the fungus is cut off 
 with scissors it will soon return unless the infection is controlled and 
 the wound begins to cicatrize and contract. 
 
 Focal or Jacksonian Epilepsy, named after Hughlings Jackson, 
 who particularly studied the condition in 1873, was referred to at 
 p. 584, as an occasional symptom of brain tumor. It is characterized 
 by convulsive attacks beginning in one muscle or group of muscles, 
 gradually spreading until finally a generalized convulsion ensues. 
 Consciousness may persist until the convulsions become general, 
 or it may not be lost at all. It is thus distinguished from ordinary 
 ("idiopathic") epilepsy, in which the fits are general from the first, 
 
FOCAL EPILEPSY 591 
 
 and in which unconsciousness ushers in the attack.* Jacksonian 
 epilepsy is believed to be due either to some localized cortical lesion, 
 or, rarely (and then most often in children and women), to some 
 peripheral sensor}' irritation, arising from a painful cicatrix or other 
 lesion such as eye-strain, dental disorders, genital affections, etc. 
 
 In cases due to cortical lesion the most frequent cause, apart from 
 tumor, is the result of old trauma; this may have been a depressed 
 fracture, or a meningeal hemorrhage producing a meningo-cortical 
 adhesion, a cyst, or a cicatrix. Similar lesions may be the result 
 of intracranial infections, especially in children, in whom focal epilepsy 
 may develop after an attack of meningitis, poliomyelitis, etc. 
 
 Treatment. — x\s there is no medical cure for these cases, it is per- 
 fectly justifiable to consider what benefits may be gained from surgical 
 intervention if a definite lesion can be located. Nor should the 
 surgeon hesitate to operate for any surgical condition in another 
 part of the body in an epileptic patient merely because occasional 
 fits occur; for it happens occasionally that cure of a lesion not sus- 
 pected of having any causal relation with the epilepsy results in 
 freedom from, or at least in a lessening in frequency of the convulsions. 
 
 If a meningeal or cortical lesion is suspected, the centre controlling 
 the muscle group first aflfected is exposed by an osteoplastic flap. 
 Depressed bone is removed; adherent dura is excised, and the re- 
 formation of adhesion is prevented by the interposition of Cargile 
 membrane, silver foil, or similar substance. Free transplants of 
 fascia lata have been used with success. Little can be done for lesions 
 in the cerebral substance. The proper centre may be identified by 
 faradization of the cortex. Kocher (1899) believed a decompression 
 operation alone was of benefit. The sooner any operation is done 
 after the development of focal epilepsy, the more apt is it to be cura- 
 tive; and if all head injuries received efficient treatment at the time 
 of the original accident, the number of cases of Jacksonian epilepsy 
 would be much decreased. 
 
 1 Advances in knowledge constantly are diminishing the number of cases of true 
 "idiopathic" epilepsy, and it is not impossible that only our ignorance prevents 
 a recognition of an organic lesion in all such cases. 
 
CHAPTER XVIII. 
 SURGERY OF THE SPINE. 
 
 Spina Bifida, or Hydrorrachis.— Under these names are included 
 several forms of congenital malformation oi the spine, due to failure 
 of proper coalescence in the embryonal medullary plates. Myelocele, 
 or Rachischisis, is the most complete form. In this the skin is defi- 
 cient, and there is exposed on the back of the infant, usually in the 
 lumbar region, a dark red area covered by endothelium, which is con- 
 tinuous above and below with the central canal of the spinal cord. 
 The infant often presents other serious malformations, and usually 
 is stillborn or dies within a few days from continual leakage of 
 cerebrospinal fluid, or from infection. Syringomyelocele: Here the 
 central canal of the spinal chord is distended with fluid, the surround- 
 ing chord is compressed and atrophic, and protrudes as a cystic tumor 
 through a defect in the vertebral laminae. The protrusion, which is 
 covered by skin, or membrane, usually occurs to one side, and not 
 in the midline. Moiingomyelocele is by far the commonest of these 
 deformities, occurring in nearly two-thirds of all cases of spina bifida. 
 The cystic protrusion is formed by fluid which collects in the meshes 
 of the arachnoid, and the roots of the spinal nerves are spread out 
 over the walls of the sac. If the sac presents a dimple or furrow on its 
 surface it is probable that the cord itself is adherent. The laminae of 
 one or several vertebrae may be deficient. Meningocele, in which the 
 protrusion involves only the spinal membranes, and never the nerve 
 roots or the cord itself, occurs only in about 8 per cent, of cases. 
 The tumor is small, covered throughout with healthy skin, never 
 presents a dimple or a furrow, and usually is more or less pedunculated, 
 its orifice of communication with the spinal canal being small. In 
 meningomyelocele, on the contrary, the protrusion is large, sessile, 
 and communicates with the spinal canal through a large defect; and 
 while healthy skin may extend upward from its base some distance, the 
 summit of the protrusion usually is covered by membrane which easily 
 becomes inflamed and sloughing is frequent. Paralysis of the parts 
 below the tumor points to a condition of meningomyelocele rather 
 than of pure meningocele. If there is a defect in the bony wall of the 
 vertebral canal, without the protrusion of any of its contents, the 
 condition is known as Spina Bifida Occulta; this usually is accom- 
 panied by hypertrichosis of the region affected. In very rare cases 
 there has been a defect in the anterior portions of the vertebral canal, 
 constituting Spina Bifida Anterior. 
 
 Symptoms. — Besides the presence of a cystic growth, usually in the 
 lumbar or sacral regions of the spine, it may be possible to ascertain 
 
INJURIES OF TllK SI'IXE 
 
 693 
 
 by j)ali)ati()ii or .skiu|;raphic exaniimitioii that a defect exists in tlie 
 vertebra?. Compression of the spina bifida usually causes increased 
 tension in the cranial fontanelles, and may prcjduce convulsions. 
 Tension of the cyst is increased durinfi; expiration, and when the child 
 is in the npri<;ht position. 
 
 Treatment. — 1. // tJicre are oilier serious malforiiiatioiis, or extensive 
 parah/sis, no radical treatment should be adopted, as most of these 
 patients will die within the first 
 year under any circumstances. 
 Efforts to avoid infection should 
 be made, by preventing excori- 
 ation of the sac. If such patients 
 survive more than five years, 
 operative treatment, as detailed 
 below, will be proper. 2. // there 
 are no other serious malformaiions 
 and no parali/ses, the treatment to 
 be adopted depends upon the con- 
 dition of the coverings of the spina 
 bifida: when these are healthy, as 
 in most cases of pure meningocele, 
 operation should be postponed until 
 the child is five years of age; when 
 the coverings are thin or membran- 
 ous, the risk from delay is as great 
 as, if not greater than that from 
 early aseptic operation. Imme- 
 diate operation may be required at any time for rupture of the sac, 
 but when a choice is possible, operation during the second or third 
 month of life is to be preferred (Lovett, 1907). 
 
 Operation usually consists in excision of the sac, preserving healthy 
 skin coverings, and carefully dissecting free adherent nerves, but 
 cutting away those that cannot be preserved, as the\' probablj' are 
 functionless (Carson). The sac walls are then overlapped, as in radical 
 cure of umbilical hernia, and the muscles and skin are sutured in 
 separate layers, and the wound is closed tightly without drainage. 
 The death rate following operation is from 25 to 35 per cent., and 
 hydrocephalus sometimes develops as a result. Reference was made 
 at p. 556 to Heile's employment of drainage of the sac into the peri- 
 toneal cavity by means of subcutaneous silk threads, with coincident 
 cure of a complicating hydrocephalus. 
 
 Sacro-coccygeal Tumors. — See Chapter IV. 
 
 032. — Spina bifida. Age eightceu 
 months. Orthopaedic Hospital. 
 
 INJURIES OF THE SPINE. 
 
 Strains. — Strains of the back, affecting the muscular and aponeu- 
 rotic structures, are much more frequent than true sprains affecting the 
 spinal joints. According to the severity of the injury, these patients 
 38 
 
594 SURGERY OF THE SPIXE 
 
 are to be treated by rest in bed, or as ambulatory cases, support being 
 provided during the painful stages by adhesive plaster strapping or 
 plaster of Paris jackets. Restoration of function may be aided later 
 by massage. 
 
 Sprain-fracture. — Sprain-fracture of the transverse processes of the 
 lumbar vertebrae, unilateral, occasionally occurs from muscular action. 
 Tanton (1910) has collected 17 cases of this injury. Skillern (1913) 
 has reported a case of sprain-fracture of a spinous process. 
 
 Static Lesions of the Lumbar Spine and Spondylolisthesis are 
 discussed in Chapter X\'I. 
 
 Concussion of the Spinal Cord. — This term has been used to 
 define a condition supposed to be more or less analogous to con- 
 cussion of the brain fp. 569). It implies that there has been injury 
 to the spinal cord without lesion of the vertebral column; and while 
 some hold that the symptoms which follow a supposed injury have no 
 pathological basis for their existence, being merely one form of neurosis, 
 other authorities believe that actual changes in the cord have taken 
 place, and have left more or less irreparable damage. Many of these 
 patients receive their injury in railroad accidents, and the condition 
 which ensues is popularly known as "Railway Spine," or, because of 
 the improvement which usually follows the settlement of a suit for 
 damages, as "Litigation Spine." As a matter of fact it is probable that 
 most of these cases should be considered severe strains or sprains of 
 the back, and the surgical treatment is the same. For the hysterical 
 symptoms which sometimes ensue, the patients should be referred 
 to a neurologist. 
 
 Hematomyelia. — Hematomyelia, or hemorrhage into the substance 
 of the spinal cord, sometimes occurs from sudden twists or angula- 
 tions of the vertebral column, perhaps from a self-reduced subluxation, 
 without discoverable gross lesion of the spinal column. It is seen 
 oftenest in the lower cervical region (Thorburn, 1S89). and causes 
 paralysis depending upon the extent of the lesion. Usually the lower 
 extremities recover from the paralysis more or less rapidly, though 
 they may remain spastic, while the flaccid paralysis of the upper 
 extremities continues. There is dissociated anesthesia below the 
 level of the lesion: that is, while tactile sensation is preserved, tem- 
 perature and pain sense are diminished or lo-t. Spinal puncture 
 shows nf) blood in the cerebrospmal fluid. 
 
 Stab Wounds. — Stab wounds, involving the spinal cord are very 
 rare. From unilateral lesion a monoplegia may result. It is best 
 in civil life to explore such wounds, by laminectomy (p. 601), as it 
 may be possible to repair the injury. 
 
 Fractures and Dislocations of the Spinal Column. — Fracture and 
 dislocation occur as a combined lesion in about (^0 per cent, of cases 
 of injury of the spinal column, while isolated fractures and disloca- 
 tions form each about 20 per cent, of these injuries. The spine is 
 most subject to injury where its mobile and immobile portions meet, 
 that is, in the lower cervical and the dorso-lumbar regions. Pure 
 
IXJIRIES OF rilE SPINE 
 
 595 
 
 dislocations are very rare except in the cervical rej^ion, as the form of 
 the articular processes renders fracture almost a necessary complica- 
 tion in other portions of the vertebral column. Fractures of the laminae 
 or spiiH.us processes usually occur from direct \iolcnce, as in jiuiishot 
 wounds, or in falls from a height directly upon the hack, impiuf^dnj^ 
 on a stone, fence rail, etc. The most common lesion is a crushing 
 fracture of the bodies of one or more vertebra^, attended by forward 
 dislocation of the vertebra next above, the disjunction of the articular 
 j)r()cesses taking place on one or both sides (Fig. b.'33). Such cases 
 generally are caused by sudden hyperflexion, with twist, of the spinal 
 column, as falls from a height on to the feet or the buttocks, crushing 
 injuries from above acting upon the shoulders, or from a dive into 
 shallow water, ^'iolence acting upon the head or neck usually pro- 
 duces a lesion in the lower cervical region, and that acting from Ijelow 
 determines lesions in the dorso-lumbar portion of the spine. 
 
 
 ^■l. >^ ^^^^H 
 
 
 
 ^^^^^^^SS^^flH 
 
 P'lG. t)33.- — Fracture dislocatirm of eleventh and twelfth thoracic vertebrae. From a 
 specimen in the Mutter Museum of the College of Physicians of Philadelphia. 
 
 Symptoms. — These may be divided into those due to injury of the 
 vertebral column, and those caused by accompanying lesions of the 
 spinal cord. It is said that the cord escapes injury in about one-third 
 of the cases. 
 
 Symptoms from Injury of the Vertebral Column. — Of these, deformity 
 is of most value. This may consist in a depression at the point of 
 injury, especially when the fracture is from direct violence, the spines 
 and laminae being driven forward; or it may indicate that there is a 
 partial forward dislocation of the vertebra whose spine is depressed. 
 Such a depression is most apt to be found in a dorso-lumbar injury. 
 In some cases there is angular deformity, a well defined kyphos existing 
 
596 
 
 SURGERY OF THE SPINE 
 
 at the point of injury and indicating the collapse of a vertebral body, 
 causing separation of the spinous processes. Rotatory deformity is 
 seen oftenest in the cervical region, in cases of unilateral dislocation: 
 the head is twisted away from the side which is luxated, and this 
 side maj' be unduly prominent; the sterno-mastoid muscle on the 
 uninjured side is more tense than is that on the injured side. Other 
 symptoms of fracture, such as mobility and crepitus, seldom are 
 present; but persistent localized tenderness is very suggestive of 
 vertebral injury, and in the cervical region muscular spasm, producing 
 rigidity of the neck, is a very usual symptom, especially in lesions of 
 the vertebrne without injury of the cord. A good skiagraph may be 
 necessary to assure the diagnosis in obscure cases. 
 
 Symptoms from Injury of the Spinal Cord. Motor Symptoms. — Motor 
 paralysis is the most striking and one of the most constant symptoms, 
 
 and involves all the muscles below the 
 seat of the lesion. Usually it follows 
 the injury immediately, and then indi- 
 cates extensive destruction of the cord, 
 as a rule from crush due to displaced 
 l)one (Fig. 634). If the onset of the 
 paralysis is delayed, it probably is the 
 result of hemorrhage either within the 
 cord {hematomyelia) or in the arach- 
 noid spaces. The former has been con- 
 sidered above; in the latter, which is 
 known as hematorrachis, paralysis of 
 motion usually is more marked than is 
 that of sensation, and gradually ex- 
 tends upward, perhaps in the course of 
 a few hours. In all cases the primary 
 paralysis is flaccid, and the patient 
 is free from pain, at least in the early 
 stages. If the paralysis becomes spastic 
 very soon (12 to 24 hours) after the 
 injury, and if the reflexes are present, 
 it usually indicates only partial de- 
 struction of the cord, from contusion, 
 pressure from displaced bone, hematorrachis, etc. Paralysis which 
 first develops some days after a spinal injury usually is due to 
 inflammatory exudation or blood-clot. But lumbar puncture rarely 
 shows blood in the cerebrospinal fluid. 
 
 In the cervical region, symptoms of cord injury may be obscured 
 at first by those due to cerebral concussion, caused by the same injury. 
 If the lesion is above the fourth cervical segment, causing paralysis 
 of the diaphragm, immediate or rapid death is usual. Symptoms 
 from paralysis of the cervical sympathetic may be present. Char- 
 acteristic attitudes may be assumed owing to unopposed action of 
 intact muscles (Fig. 635). 
 
 Fig. G34. — CrushiiiK fracture of 
 first lumbar vertebra. Mutter 
 Museum. 
 
IXJlh'lIiS OF HIE SI'INE 
 
 of)^ 
 
 It" the lesion is below llie .-ecoiid lumbar \ertebra, i)aralysis may be 
 absent or only partial, o\viii<; to the fact that the spinal eord itself 
 does not extend beyond tliis lex'el, and the injury may invohc only 
 some of the branches of the eauda ('(juina. In rare eases onl\' unilateral 
 (homolateral) paralysis may exist; this is much more usual in stab 
 and gunshot wounds than in eases of fraeture-disloeation. 
 
 At a later date (after a week or ten days) it is very usual for the 
 patient to experience i)ainful spasms in the paralyzed limbs; and as 
 cicatricial chanf:;es in the cord progress the type of paralysis becomes 
 spastic, and contractures develop (Fig. 244). 
 
 Fig. 635. — Fracture of cervical vertebrae. Characteristic position of arms when the 
 lesion is above the fourth cervical segment. (Thorburn's position.) (See Fig. 6.36.) 
 Episcopal Hospital. 
 
 Sensory Symptoms. — Sensation is lost over an area corresponding 
 to that of paralysis of motion, and the upper limit of the motor and 
 sensory paraly.sis is sharply defined, thus determining the level of the 
 injury (Fig. 63()). Pain rarely is severe, though a zone of hyperesthesia 
 is not infrequent at the upper border of the anesthetic area. Shooting 
 pains, from irritation of the sensory nerve roots, are more common 
 in partial cord lesions, and often occur when recovery from severer 
 lesions is beginning. Dissociated anesthesia, as already mentioned, 
 is frequent in hematomyelia. 
 
 Bed-sores, especially over the sacrum and heels, are very prone to 
 develop in cases of spinal injury, being described as due to trophoneu- 
 rotic disturbances. Whatever is the true explanation, the probability 
 of their early development (within two or three days) always should 
 be borne in mind, and preventative measures instituted. 
 
 Abdominal and Vesical Symptoms, — Owing to the motor paralysis 
 affecting the muscles of the abdominal wall, and perhaps the muscular 
 tunics of the intestines, tympanites develops. If, as is usual, the lesion 
 
598 
 
 SURGERY OF THE SPINE 
 
 N. to sphincte 
 Coccygeal n 
 
 _iV. to rectus lateralia 
 ^'Ito rectus antic, minor 
 ^AiuistuDiosis Willi hyijorjlassal 
 
 _ Anastomosis with pnetnnngastric 
 
 _N. to rectus antic. major. 
 ..N. to mastoid region. 
 ._Great auricular n. 
 
 -Transverse cervical n. 
 N. to Trapezius, Any. Scap. and Rhomboid. 
 
 ,Supra-ctavicular n. 
 
 .Supra-acrumial n. 
 
 .Phrenic n. 
 
 N. to levator any. scap. 
 
 ^V. to rhomboid 
 
 . — Subscapular n. 
 
 . _ Subclavicular n. 
 
 X. to peetoralis major. 
 
 Circumflex n. 
 
 ^^Musculo-cutaneou.-i u. 
 
 Median n. 
 
 Radial n. 
 
 _Ulnar n. 
 
 _laternal cutaneous ». 
 
 ..Small internal cutaneous i 
 
 Ilio-hijpocjaxtric n. 
 lUo-inguinat n. 
 
 Ejcternal cutaneous n 
 Genito-crural n. 
 
 Anterior crural i 
 Obturator n. 
 
 Superior gluteal n. 
 
 -N. to pyriformis 
 .N. to gemellus super. 
 
 Small sciatic n. 
 S'Jiatic n. 
 
 Fig. 636. — The relation of the segments of the spinal cord and their nerve roots to 
 the bodies and spines of the vertebrae. (Dejerine et Thomas, Mai. d. 1. Moelle Epinifere, 
 Paris 1902.) 
 
INJLIHES OF 'rilK Sl'lSK 599 
 
 is above the spinal centres for tlie bladder and rectum (in the second, 
 third, and fourth sacral se<2;ments), there is rHeniion uitit ovcrjloir (.f 
 the urine and feces, as the voluntary impulses from the cerebrum 
 cannot reach the spinal centres, and the sphincters remain tonicaily 
 contracted until overflow occurs. The bladder becomes distended, 
 and only the surplus urine dribbles away; feces accunuilate in the 
 rectiun, and this is emj)tied only by enema, or finally by exhaustion 
 of the sphincter. If, however, what is very rare, the lesion is so 
 low as to damatije these centres themselves, or the nerves between 
 them and the bladder or rectum, then true incontinence of urine and 
 feces occurs, the bladder remaining empty, while the urine and 
 feces are passed in\oluntarily, and more or less continuously. Ci/n- 
 iitis is very hard to prevent, as a consequence of the habitual use of 
 the catheter which is required as long as retention persists. Fnnpisin, 
 occurring soon after the injury, is common, especially in younger 
 patients, and is said to be more frequent in severe and high lesions 
 than in those at a lower level, or those in which there is only partial 
 destruction of the cord. 
 
 Prognosis. — It long has been a rule of thumb that when the frac- 
 ture is in the cervical spine the patients will live a week, those with 
 fracture of the thoracic spine a month, and those with fracture 
 of the lumbar spine a year; and this may still be considered a fairly 
 accurate prognosis when there is evidence of complete transverse 
 lesion of the cord. But in the cervical region it is not unusual 
 for the cord to escape injury, mainly owing to the large size of the 
 spinal canal. J. and A. Boeckel (1911) have collected 36 such cases. 
 In injuries of the thoracic and lumbar regions, life may be preserved 
 indefinitely if such complications as bed-sores, cystitis, and pyoneph- 
 rosis can be prevented; and if the cord is not totally destroyed, careful 
 nursing may enable a certain amount of power to be regained. 
 
 Treatment. — No hesitancy should be felt in reducing any deformity 
 present, especially in the cervical region; but this should be done 
 judiciously, and with a clear idea of the mechanism of the injury. 
 The fact that one or more such attempts have resulted in the patient's 
 immediate death, demonstrated nothing, as pointed out by Mal- 
 gaigne, as long ago as 1843, but that the attempts were unskilfully 
 made by an incompetent person. In studying nearly 400 cases of 
 spinal injury, John Ashhurst, Jr. (1867) found that in the treatment 
 of dislocations in the cervical region the mortality had been nearl}^ 
 four times greater when no attempts were made to reduce the 
 deformity, than when this was undertaken by extension, rotation, 
 etc. Walton (1892) systematized the reduction of these injuries, 
 omitting attempts at extension (longitudinal traction), which he 
 demonstrated to be useless, and employing only " retro-lateral flexion 
 and rotation," in the unilateral cervical dislocations, which are the 
 most frequent cases. Reduction is accomplished, after etherizing 
 the patient, in this manner: the surgeon stands behind the seated 
 patient, and grasps the head between his hands; the head is then 
 
600 SURGERY OP THE SPINE 
 
 tilted backward, and flexed slightly away from the dislocated side, 
 so as to release the dislocated articular process from the interver- 
 tebral foramen of the vertebra next below, where it is usually caught. 
 The head is then rotated so as to carry the dislocated side ))ackward. 
 Reduction of the deformity may be attended by an audible or pal- 
 pable click. The patient should remain in bed, with the head and 
 neck immobilized by plaster of Paris dressings, or by sand-bags with 
 weight extension (as in cervical Pott's disease, p. 609) for a couple 
 of weeks, and some retentive appliance should be worn for some 
 weeks longer, or until the ruptured ligaments have had a chance to 
 heal. Bilateral cervical dislocations may be reduced by the same 
 method, applied to each side separately. The deformity from frac- 
 ture, seldom present except in the thoracic and lumbar regions, 
 usually is best corrected by hyperextension of the spine. 
 
 In every case with cord injury, the patient should be kept on a 
 water bed, with head and foot extension, as in tuberculosis of the 
 spine (p. 609) ; and the utmost care should be taken to prevent the 
 development of bed-sores (p. 62). The bladder should be drained 
 by an inlying catheter, if there is retention of urine; and the bowels 
 generally have to be moved by enemas. In most cases nothing further 
 can be done than to keep the patient comfortable by careful nursing. 
 If life is preserved, efforts must be made to maintain the nutrition 
 of the paralyzed parts by massage; the development of deformities 
 from contractures (Fig. 244) should be guarded against, though these 
 may be corrected later by tenotomies; and eventually such orthopedic 
 apparatus as is indicated should be provided, as in this way patients 
 otherwise nearly helpless may regain some power of locomotion. 
 
 The Quesiion of Operation. — In cases where, after the first few days, 
 it seems that the cord has not been completely destroyed — as evi- 
 denced by persistence of reflexes, early development of spasticity, 
 with shooting pains, spasmodic contractions, etc. — it is justifiable to 
 expose the injured cord by laminectomy, in the hope that evacuation 
 of blood-clot (almost always extradural) or even the removal of 
 counter-pressure on the cord by the laminae and arches, may accel- 
 erate the cure. But it is in just such cases as these that a fair amount 
 of improvement may occur without operation; yet as this cannot be 
 certain beforehand, and as operation in such carefully selected cases 
 does not increase the mortality, I think it should be employed. Very 
 early operation (on the day of injury, if possible), is proper in all cases 
 where the spines and laminae have been driven inward against the 
 cord by direct violence; since in such cases it is reasonably' sure that 
 the displaced fragments continue to compress the cord, or that hema- 
 torachis will develop later. The same is true of gunshot wounds of 
 the vertebral column, in civil life, involving the arches; these should 
 be treated by laminectomy and removal of displaced fragments, 
 whether or not there are cord symptoms. 
 
 In other cases, with symptoms of complete transverse lesion, in 
 most of which the osseous lesion is collapse of the vertebral bodies, it 
 
INJURIES OF THE SI'INE 
 
 cm 
 
 is oxtreiiH'ly j)r(tl);il)l(' tliiit the cord luis liccii cruslicd ])\ tlic (iisphiccd 
 hoiu' at the tinic of tlii' accident, hut that there is no coiitimiiii^ j)res- 
 siire from the hone; and even did such pressure exist, it is extremely 
 iniprohahle that relief of the cord from it would in any way promote 
 recovery of function. 
 
 It is artjued hy some that ah fractures of the vertehrie should l)e 
 treated by immediate operation, as in the case of fractures of tlie 
 cranium. But the cases are not similar; for in fractures of the cranium 
 we <lo not operate to repair damage to the brain (which is irreparable), 
 but for the ])urpose of preventing; infection, jireventinif or relie\ing 
 intracranial ])ressure (from efi'used l)lood or displaced bone), or pre- 
 venting the subsequent development of Jacksonian epilepsy. In 
 the case of vertebral fractures, infection is very little to be feared, 
 none of these fractures except those from gunshot wounds being com- 
 pound; while intraspinal pressure, in the sense in which we speak 
 of intracranial pressure, scarcely exists, save in the rare cases of 
 rapidly ascending paralysis from hematorachis. In spinal fractures, 
 therefore, operation should be undertaken, not to repair irreparable 
 damage to the cord, but as indicated above only when it is probable 
 that some extramedullary lesion (displaced bone, l)lood-clot) causing 
 continuing pressure can be removed. 
 
 Fig. 637. — -Large bone cutting forceps for laminectomv, with blades angled on 
 
 the flat. 
 
 Laminectomy. — The patient lies prone. A skin-flap is turned 
 aside, exposing the spinous processes, and the muscles are detached 
 by blunt dissection from the laminae of one side. Hemorhage, 
 which is profuse, is readily controlled by pressure of hot gauze. 
 Hemostats are useless. The laminse of the other side are then cleared. 
 When the requisite number of arches (usually three or four) have 
 been thus exposed, the supraspinous ligament connecting the lower 
 spinous processes is divided, and a large bone cutting forceps, with 
 blades angled on the flat (Fig. 037), is passed into the opening and the 
 requisite number of spinous processes is removed from below upward. 
 A crown trephine is then employed to open the spinal canal, and the 
 opening thus made is enlarged by rongeur forceps, biting aw^ay the 
 laminae as far as the articular processes. This method is quicker and 
 safer than the use of chisel and mallet. When the w^ound is dry the 
 dura is opened by a median longitudinal incision, allowing the cerebro- 
 spinal fluid to escape slow'ly. The cord is inspected, and spicules of 
 
602 SURGERY OF THE SFIXE 
 
 bone, blood-clot, etc., may then be removed. Usually it is not possible 
 to tell from the appearance of the cord whether or not it is the seat 
 of a complete transverse lesion. Some days or weeks after the injury 
 the cord, above and below the lesion, may seem swollen. If the cord 
 is completely severed, attempts should be made to suture it^ with fine 
 chromic catgut, introduced as mattress sutures with a fine curved 
 needle. The dura should not be tightly sutured, and it usually is well 
 to leave a gauze wick for drainage down to the dural surface. The 
 wound is then closed in layers. 
 
 Traumatic Spondylitis (Kummel, 1891 j. — Under this term is 
 described a rarefying osteitis of the vertebrae, which develops after 
 severe contusion or fracture, and gives rise to a gradually increasing 
 kyphosis. Mauclaire and Burnier have recently (1912) collected one 
 hundred such cases. In spinal injuries, long after-treatment (plaster 
 of Paris jackets, body braces) is necessary to prevent the development 
 of such a deformity. It is treated as is tuberculosis of the spine. 
 
 Osteomyelitis. — Osteomyelitis of the vertebra is rare. Symptoms 
 of general sepsis may obscure the local affection, so that this may not 
 be detected until abscesses form, unless symptoms of compression of 
 the spinal roots or the cord sooner call attention to the vertebral 
 column. The mortality is about 60 per cent. The affected area should 
 be exposed; almost invariably it is the vertebral bodies that are 
 diseased. The cervical spine is approached by an incision posterior 
 to the sterno-mastoid, the thoracic region by an operation known as 
 costo-transversectomy (p. 614), and the lumbar spine by the retro- 
 peritoneal route, as in operations on the kidney. The abscess 
 is evacuated, and sufficient bone is removed to secure free drainage. 
 If recovery ensues, the spine must be supported as in convalescence 
 from tuberculosis of the vertebrse. 
 
 Tuberculosis of the Spine; Pott's Disease. 2— :\Iore than one-third 
 of the osseous lesions of tuberculosis are located in the vertebral 
 column. Children, from two to ten years of age, are affected oftenest, 
 and the disease is comparatively rare in adults. Two-thirds of the 
 cases begin in children under five years of age. The lesions are situated 
 almost exclusively in the vertebral bodies, and aft'ect the thoracic 
 vertebrae oftenest (over 50 per cent, of cases), and the cervical region 
 least often (about 15 per cent.). Destruction of the vertebral bodies 
 by caseous softening, with continuance of weight-bearing function, 
 explains the development of various deformiti*^s. Cold abscesses are 
 a notable feature of the disease, forming its most important complica- 
 
 * Harte and Stewart (1902j reported a case of suture of the spinal cord after 
 excision of the damaged area (three-fourths of an inch in extent), caused by bullet 
 wound; there was return of fair function in the paralyzed lower Umbs. A. R. 
 Allen (1911* has suggested immediate median longitudinal section (2 to .3 cm.) 
 of the spinal cord in the area believed to be damaged, on the theory that para- 
 plegia results from secondary compression from intramedullary edema rather than 
 from actual destruction of tJtie cord tissue by the original injury. 
 
 ^ Paraplegia resulting from this affection was first carefully studied bv Percival 
 Pott in 1779. 
 
TUBERCULOSIS OF THE SI'INE (U\ 
 
 tion. rarajjlcfjia, much less fre(iiieiit, and pr<)l)al)ly no mf)re serious 
 in its results, is the other main complication. 
 
 Symptoms. The first symptoms to attract attention may he mere 
 listlessness, a desire to sit still and to hold on to the tables and chairs 
 in walking around the room. Usually slight alterations in the gait, 
 in the manner of st()oj)ing, etc., are observed very soon. The patient, 
 like \iii\ii: in the presence of Samuel, walks "delicately," fearful to 
 make any sudden movement lest the spine be jarred. The body may 
 be held persistently to one side. In trying to pick anything off the 
 floor, instead of stooping like the normal child, by flexing the lumbar 
 spine and the i)elvis, the j)atient holds the spine rigid and upright, 
 and by flexing his knees and hips brings his buttocks almost in contact 
 with the ground. In standing, the patient may lean forward and 
 support his body by resting his hands on the thighs; in sitting he will 
 prop himself up on his hands; and in disease of the cervical region 
 may hold the chin in the hands and turn the whole body around, or 
 merely roll his eyes, instead of turning his head. At night the child 
 is restless, and sleep may be disturbed by starting pains, with their 
 attendant night-cries (p. 479). "Belly-ache" often is one of the 
 earliest complaints, being due to pain referred along the intercostal 
 nerves. Pain occasionally is referred to the buttocks or the knees, 
 when the lumbar spine is diseased. 
 
 Physical Examination, thorough and systematic, is indicated when- 
 ever any symptoms point to a possibility of spinal disease. Have 
 all the patient's clothing removed, and let him walk barefoot to and 
 fro, studying the gait in all aspects. Let him stoop forward, flexing 
 the lumbar spine and pelvis, but keeping the knees extended, until 
 the tips of the fingers touch the floor. Note any indications of 
 -discomfort so produced, and especially any break in the normal con- 
 tour of the flexed spine, which should be one continuous curve. Mus- 
 cular spasm, from underlying disease, W'ill cause loss of this rounded 
 contour, and the process of straightening up again may be attended 
 })y jerky movements. Then let the patient sit on the floor or on a firm 
 couch, and bend his body well down between his fully flexed thighs, 
 so as to flex the spine as far as possible; and note any irregularity in 
 the contour. Then lay the patient prone, and gently elevate the feet 
 in one hand, thus hyper-extending the spine (Fig. 638). Note here 
 also any area which lacks normal flexibility, or which is painful. 
 Then raise the head and shoulders from the bed, to test the flexibility 
 of the cervical and upper thoracic spine in the same manner. 
 
 When typical deformity once has appeared, diagnosis is compara- 
 tively easy. But earlier types of deformity should be recognized 
 when present. In the cervical spine, wry-neck may often be symp- 
 tomatic of tuberculosis; in the thoracic region a posterior angular 
 curvature (kyphosis) is nearly pathognomonic; and in the lumbar 
 region an exaggerated lordosis, wdth protuberant abdomen, may first 
 attract attention. Lateral deviation of the spine is seen chiefly in 
 disease in the dorso-lumbar or lumbo-sacral regions (Fig. 639) and may 
 
604 
 
 SURGERY OF THE SPINE 
 
 be due to unilateral spasm of the psoas, from incipient cold abscess. 
 Careless observation may mistake this deviation for lateral curvature 
 
 Fig. 638. — Examination for rigidity of spine in Pott's disease: the patient lies prone 
 and the spine is hyperextended by raising the feet. Orthopaedic Hospital. 
 
 Fig. 639. — Pott's disease, showing lateral 
 deviation to left. Age thirteen years. Dura- 
 tion seven months. Orthopaedic Hospital. 
 
 Fig. 640. — Pott's disease. Age seven 
 years. Duration one year, showing 
 angular kyphos. Orthopaedic Hospital. 
 
 of the spine (p. 533) ; but pain usually is absent in the latter deformity, 
 and physical examination will detect neither tenderness (abscess?) 
 nor muscular spasm. In cases where the diagnosis remains doubtful. 
 
Tl'liERCULOSlS OF TIU'J SPINE 
 
 005 
 
 tlio tuhcrciilin test (p. SI) may be tried; and under any eircimi- 
 stances the patient should he kept under strict ol)servati()n until 
 further development of symjjtoms makes the diaj^nosis certain. 
 
 J)rf()riiiify. — Tiiis requires further discussion. In the thoracic region, 
 as already noted, the deformity is characteristically anf^ular and sharj) 
 (^'i«,^ (140) ; as the disease projiresses the kyj)hos hecomes more rounded 
 [V'lii. ()41). In children it is rather an early development, and rarely 
 is absent after the lapse of a few months. In adults, on the other hancl, 
 as tlie vertebral bodies contain much more calcareous matter, the 
 disease may exist for many months, sometimes for years, before any 
 noticeable kyi)lios dc\el()i)s. In low lumbar and sacral tuberculosis 
 
 Fig. 641 . — Old Pott 's disease, age six- 
 teen years; duration since three months 
 old, showing rounded kyphos. Ortho- 
 pjedic Hospital. 
 
 Fig. G42.— Old Pott's disease. Age 
 twelve years; duration ten years. Show- 
 ing stunting of patient's height. Ortho- 
 paedic Hospital. 
 
 the deformity at any age is much less conspicuous than in the thoracic 
 and cervical regions, and may manifest itself only in a stunting of the 
 patient's height (Fig. ()42). In the cervical and lumbar regions, where 
 lordosis normally exists, the disease rarely causes more than an obliter- 
 ation of this anterior concavity, rendering the affected spine straight. 
 When a kyphos high in the thoracic region is well marked, a com- 
 pensatory liunbar lordosis may develop, giving the patient a strutting, 
 self-important air, while the lower ribs may be depressed until they 
 rest on the iliac crests, markedly flattening the chest (Fig. 643). In 
 dorso-lumbar disease, on the contrary, the ribs are elevated, marked 
 "chicken-breast" develops, and the outlet of the pelvis may be much 
 
606 
 
 SURGERY OF THE SPINE 
 
 contracted antero-posteriorly, owing to the rotation of the sacrum 
 around a transverse axis (Fig. 641). 
 
 Abscess. — As the disease affects ahnost exclusively the bodies of 
 the vertebrae, any cold abscess that develops will be found beneath 
 the anterior common ligament. This structure prevents the pus from 
 extending forward, with the 
 result that it gravitates along 
 various planes of fascia, and 
 comes to the surface in rather 
 typical locations. Only in 
 the rare cases of disease of 
 the vertebral arches is the 
 
 Fig. 643. — Cervico-dorsal Pott's 
 disease with retro-pharyngeal abscess. 
 Age twelve years; duration of disease 
 ten years. Developed dyspnea and 
 dysphagia; and sinus formed on right 
 side of neck posterior to the sterno- 
 mastoid muscle ; through this sinus 
 liquid food has been discharged, for 
 the last six months, whenever the 
 patient swallows. Orthopaedic Hos- 
 pital. 
 
 Fig. 644. — Psoas abscess from Pott's 
 disease. Age three years; Pott's disease for 
 one year; abscess for several months. Or- 
 thopaedic Hospital. 
 
 Fig. 645. — Left lumbar abscess in Pott's 
 disease. Age four years: Pott's disease for 
 one year; abscess several months. Abscess 
 treated by operation, as advised in text. 
 No return of abscess, and patient in good 
 health five years after operation. Ortho- 
 paedic Hospital. 
 
 abscess apt to point posteriorly, and then usually in the median 
 
 line. 
 
 When suppuration occurs in disease of the cervical spine, it forms 
 a retro-pharyngeal abscess; this may cause dysphagia, dyspnea, or 
 even alterations in the voice if the pus sinks so far as to compress the 
 
TVHERCVLOSIS OF THE SI'INK 
 
 GOT 
 
 larynx or distort tlie vjifj;us nerve or its laryiiji;eal branches. As such 
 ail abscess increases in size, it may rupture into tiie ])harynx and cause 
 sudden death by suti'ocation ; or, as is much more usual, may make its 
 way to the lateral asjiect of the spine, and i)oint in the neck, usually 
 behind the sterno-mastoid muscle (Fig. M'A) ; rarely it may follow the 
 cords of the brachial i)lexus into the axilla. In the lower cervical and 
 upper dorsal regions, the abscess bulges into the ])osterior mediastinum, 
 and may track along the aorta and external iliac artery until it points 
 below Poui)art's ligament; or, as is less usual, may track outward 
 along the ribs, pointing usually near their angles, and simulating costal 
 caries (p. 731), which indeed may C()mi)licate the spinal condition. 
 In the lower dorsal and lumbar regions the pus usually passes beneath 
 the internal arcuate ligament of the diaphragm, invades the psoas 
 muscle (jmnis abscefis), and points in Scarpa's triangle on the outer 
 
 ial^> 
 
 Fig. 646. — Early psoas contraction from left iliac abscess. Age eleven years. 
 Pott's disease, for four years. Abscess for eight months. Orthopaedic Hospital. 
 
 side of the femoral vessels (Fig. 644). Usually such an abscess may be 
 detected w^hile still in the iliac fossa, when it is known as iliac abscess. 
 Sometimes, instead of entering the psoas sheath, the pus passes beneath 
 the external arcuate ligament, and points in the lumbar region {lum- 
 bar abscess), simulating a perinephric abscess (Fig. ()45). A^ery occa- 
 sionally an abscess may leave the pelvis through the sacro-sciatic 
 notch and point in the buttock {gluteal abscess); and an ischio-rectal 
 abscess sometimes may be traced to the spine. 
 
 Diagnosis of Abscess. — ^These various forms of abscess should be 
 watched for. Their de^Tlopment may account for contractures 
 (especially of the psoas muscle), for an apparently inexplicable exacer- 
 bation of symptoms (pain, fever, disability), and very occasionally 
 (when the abscess ruptures into the spinal canal) for suddenly devel- 
 oped paraplegia or meningitis. 
 
 Psoas contraction is best demonstrated by placing the child on its 
 back, with its lower limbs hanging over the end of the table: the normal 
 
608 
 
 SURGERY OF THE SPIXE 
 
 limb will drop below the horizontal, while one with psoas contraction 
 will remain flexed at the hip, in spite of compensatory lordosis (Fig. 
 646). Or, with the child prone, the hip-joints may be tested for hyper- 
 extension, as in the examination for coxalgia (p. -idO). There is little 
 difficulty in distinguishing between coxalgia and psoas contraction 
 secondary to Pott's disease; in the former, the motions of the hip are 
 limited in all directions, not only in extension; and there are no evi- 
 dences of spinal disease. An iliac abscess usually is palpable, a dis- 
 tinct fulness, which is absent on the normal side, being present along 
 the course of the psoas muscle. Intraperitoneal abscesses, as from 
 appendicitis, are of much more acute development, with symptoms 
 of peritonitis, and are attended by leukocytosis. 
 
 Fig. 647. — Pott's disease ^"ilh extreme angulation, but not SufScient to cause para- 
 plegia. Note that there are present the spines of fourteen vetebrse — bodies of only seven ; 
 in other words, seven bodies have been destroyed. From a specimen in the Miitter 
 Museum of the College of Physicians of Philadelphia. 
 
 Paraplegia from Pott's disease, is the effect of a "transverse myeli- 
 tis," or degeneration of the spinal cord from pressure. This pressure 
 very seldom is caused by bony deformity from extreme angulation 
 (Fig. 647). Almost always the pressure is due to tuberculous granu- 
 lation tissue, usually extradural in situation. Rarely the rupture of a 
 cold abscess into the spinal canal will cause paraplegia, which in these 
 circumstances generally appears suddenly. In most cases the para- 
 plegia is slow in onset, the patients first becoming spastic, and only 
 gradually losing the power of locomotion. Sensation is not often lost 
 entirely, even when motion is entirely aboji.shed; but h\'pesthesia and 
 paresthesia are frequent. Complete flaccid paralysis is rare. Inter- 
 ference with the functions of the bladder and rectum occurs as in 
 fracture dislocations of the spine. 
 
 Meningitis. — See p. 579. 
 
TlliEliVLLOSlS OF THE Sl'lNE 
 
 609 
 
 Prognosis. The disease is seldom cured; in adults scarcely ever. 
 It may he arrested in childhood, and many u "hump-hack," even with 
 marked tieformity, is enahled to lead for years an active and useful 
 life. But recurrence of symptoms always is to he feared. Very few 
 patients die as a direct result of the disease, and then mostly from 
 complications, such as tul)erculous menin<;;itis or amyloid defeneration 
 of the ^■iscera; hut hefore the disease hecomes latent ])rol)ahly one 
 patient out of every three affected will die from intercurrent maladies 
 which would have been survived, had not the viscera, particularly 
 the heart and lungs, been so distorted by the spinal deformity. Neither 
 an unopened abscess nor the onset of paraplegia seems to render the 
 prognosis more grave; but the rupture of an abscess, w'ith the secondary 
 infection which this entails, opens a door, as Calot says, through which 
 death soon enters. 
 
 Fig. 648. — Extension from head and Ijoth feet for Pott's disease. Orthopaedic 
 
 Hospital. 
 
 Treatment. — To secure rest for the diseased spine recumbent treat- 
 ment is almost indispensable, and in the acute stages is imperative. 
 This at once removes the superincumbent weight. The use of the 
 Bradford frame (Fig. 497), to which the child is strapped, largely pre- 
 vents motion in the spine, and immobilit}- is further favored by head 
 and foot extension (Fig. 648). Meanwhile, the patient should be kept 
 in the open air, night as well as day whenever possible, and all the 
 general measures useful in surgical tuberculosis should be adopted 
 (p. 82). During recumbency it is especially important to prevent 
 "pointed-toe deformity," which is very apt to develop if the foot is 
 39 
 
610 
 
 SURGERY OF THE SPINE 
 
 unsupported and kept constantly in the equinus position by the weight 
 of the bed-clothes. Careful trained nursing is indispensable. A 
 nurse trained especially in this work is desirable whenever her services 
 can be obtained. 
 
 If recumbent treatment can be instituted before deformity develops, 
 it may be possible to secure arrest of the disease, and to prevent the 
 occurrence of subsequent deformity. As in the case of tuberculous 
 coxitis, the only patients I have seen whom I could consider really 
 cured of the disease, without impairment of function, were those in 
 whom such treatment was adopted before the diagnosis was entirely 
 certain. When once a kyphos has developed it is very seldom that 
 surgery can do anything better than to prevent increase of deformity. 
 Whitman prefers to treat early cases on a frame which keeps the spine 
 hyperextended ; this treatment is not applicable when fixed deformity 
 already exists, and is open to the theoretical objection that it prevents 
 collapse of the diseased vertebral bodies and thus hinders ankylosis, 
 which should be encouraged, as the only chance of permanent cure. 
 At one time Calot (1896) was an advocate of forcible correction of 
 any existing deformity, the patient being anesthetized ; but a thorough 
 
 trial of the method has caused 
 it to be abandoned not only by 
 other surgeons but by Calot 
 himself. It was found that the 
 death rate was markedly in- 
 creased (shock, traumatic pneu- 
 monia, miliary tuberculosis, 
 spinal meningitis, etc.), and 
 that the ultimate cure of the 
 disease was not accelerated nor 
 the final deformity diminished. 
 When all symptoms of the disease 
 have been absent for two or three 
 months at least, ambulatory treat- 
 ment may be tried with great 
 caution, and never without efficient 
 support to the spine. The plaster 
 jacket, when properly applied, is 
 a most efficient support. It may 
 be applied with the patient re- 
 cumbent, or suspended by the 
 head and shoulders, the heels just clearing the floor (Fig. 649). For 
 most cases of thoracic and lumbar disease I think the prone position 
 is preferable (Fig. 650) : the child lies on a sling attached at both ends, 
 by a bar and ratchet, to a Bradford frame; the sling is left just lax 
 enough to allow slight hyperextension of the spine, and is included in 
 the plaster bandages, being slipped out after the plaster jacket has 
 dried. With a seamless undershirt next the skin, and all bony promi- 
 nences (pelvis, kyphos, axillse) well padded with saddler's felt, such a 
 
 Fig. 649. — Application of plaster jacket 
 with patient suspended. Orthopaedic Hos- 
 pital. 
 
rUHERCCLOSlS or TIIK SPINE 
 
 Oil 
 
 jacket may he worn for several moiitlis in comfort. The sur^n;on slionld 
 smell the Cast all over every few weeks, and thus may detect very 
 earlv anv evidence of excoriation. As an additional ^Miard aj;ainst 
 
 Fig. GoO.- 
 
 -Position for applying plaster jacket in Pott's disease. 
 Hospital. 
 
 OrthopiL'dic 
 
 such an occurrence, "scratchers" may be inserted next the skin before 
 the jacket is applied : these are long pieces of bandage, with their pro- 
 truding ends sewed to each other, and are to be drawn up and down 
 every day or so, to keep the skin in good 
 condition. For high dorsal (above the 
 eighth thoracic vertebra) or cervical 
 disease the head and neck must be im- 
 mobilized also; and in such cases it is 
 more convenient to apply the jacket 
 with the patient suspended. The front 
 of the cast should be cut away to 
 diminish its weight (Fig. 651). 
 
 Braces. — These depend more on fix- 
 ation (limitation of movement) _ than 
 on support in the sense of relief of 
 weight-bearing. Davis's brace (Fig. 
 652) (1898) takes a fixed point of sup- 
 port at the pelvis (between iliac crests 
 and great trochanters) by means of a 
 malleable steel band; over the iliac 
 crests pass well-padded straps, attached 
 behind and in front to the pelvic band, 
 which eft'ectually prevent the brace 
 from sliding downward. Up from the 
 pelvic band on each side of the spine 
 runs a light steel bar, connecting 
 through a cross-bar above with crutch 
 pieces under the axillae; these are sup- 
 ported below by steels attached to the 
 pelvic band in the mid-axillary line. 
 Nothing passes over the shoulders, as the object is not to hang the 
 apparatus from the shoulders, but to support the weakened spine from 
 below. The brace is thus fixed below at the pehis and abo^'e at the 
 
 Fig. 651. — The plaster of Paris 
 jacket for upper dorsal disease. 
 The jacket is trimmed away above 
 and below, and the large abdominal 
 window is cut to allow of free 
 breathing and feeding. (Cheyne 
 and Burghard.) 
 
612 
 
 SURGERY OF THE SPINE 
 
 shoulders, and presses forward on the transverse processes at the 
 level of the kyphos, thus tending to hyperextend the spine and 
 relie^•e pressure on the bodies of the vertebrae. If the lesion is 
 above the eighth thoracic vertebra it usually is desirable to support 
 the head also, by an attachment to the spinal uprights. When 
 
 ambulatory treatment is first com- 
 menced, the apparatus should be worn 
 at night as well as during the day, of 
 course being removed once daily for 
 bathing; but the patient never should 
 he in any other than the recumbent 
 yosiiion except ivhen the sjnnal support 
 is in place. It should be taken off 
 only after he lies down and should be 
 put on again before he even sits up. 
 
 Some support of this kind scarcely 
 ever can be dispensed with; when it 
 is abandoned symptoms nearly invari- 
 ably return. This has been demon- 
 strated to be a fact in so many cases 
 that it is almost foolhardy for a sur- 
 geon to tell a patient to throw away 
 his braces and go without support. 
 Only after many long months of free- 
 dom from symptoms is it desirable 
 to dispense with the crutch pieces of 
 the apparatus, the brace then con- 
 sisting merely of a pelvic band, 
 spinal uprights, and shoulder-straps. 
 Such an apparatus gives practically 
 no support, but prevents dangerous 
 degrees of movement in the spine. 
 
 Operative fixation of the spine, in 
 recent cases of Pott's disease, has been 
 tj employed by several surgeons. Lange 
 inserts two steel bars, one on each side 
 of the spinous processes, and fastens them above and below to the 
 transverse processes of healthy vertebrae. Albee splits the spinous 
 processes of vertebrae over the seat of disease and of two more 
 above and below, and inserts in the cleft a sliver chiselled off the 
 patient's tibia; when this grows fast firm ankylosis is secured. Hibbs 
 chisels partly through the spinous processes at their base, turns each 
 one down until it comes into contact wdth the base of the spinous 
 process next below^ and thus covers the diseased region of the spine 
 with a solid bridge of bone. Of these various measures I believe Albee's 
 operation of bone transplantation is the best. I have employed it 
 in seven cases, and apart from one death from pneumonia, all the 
 patients have shown marked improvement; but in one (Fig. 653) the 
 
 Fig. (i,jlj. -liracc lui rervical or 
 high dorsal Pott's disease. Ortho 
 psedic Hospital. 
 
TUBERCULOSIS OF THE Sl'INE 
 
 013 
 
 transplant later hecanio loosened at its lower extremity, and a new 
 kyplios developed. 
 
 Treatment of Abscess. — -The general prineiples wliieh should guide 
 surgeons in the treatment of tuhereulous abseesses and sinuses have 
 been diseussed in Chapter XV. If reeumbeney and immobility do 
 not cause retrogression of the abscess, and still more so if it continues 
 to enlarge, it should be incised through healthy overlying tissues, 
 should be carefully evacuated, its cavity should be thoroughly wiped 
 out with iodoform gauze, and the incision should be tightly closed by 
 several layers of sutures (see Fig. 045). A retropharyngeal abscess 
 
 Fig. 653. — Bone transplant in lumbar spine. Epi.scopal Hospital. 
 
 requires early evacuation, to prevent rupture into the pharynx or 
 secondary infection from the same source. In adults local anesthesia 
 is sufficient. An incision is made, in the lines of the skin, at the pos- 
 terior border of the sterno-mastoid muscle, and this is defined and 
 drawn forward; usually the bulging abscess is found just beneath the 
 muscle, and may be opened by Hilton's method (p. 51). The abscess 
 wall, the muscle, the platysma, and the skin, should be sutured if 
 possible in separate layers. An abscess in the posterior mediastinum 
 rarely requires drainage ; it is exposed by excision of the heads and necks 
 of the ribs, with the corresponding transverse processes of the diseased 
 
614 SURGERY OF THE SPINE 
 
 vertebra? (costo-transversectomy) . Injury to the intercostal nerves, 
 and especially to the i)leura should be avoided. An iliac abscess may 
 be opened by a small McBurney muscle-splitting incision as in appen- 
 dicitis (p. 820), without fear of invading the peritoneum if the incision 
 is made close to the ilium and the dissection keeps close to iliac fossa. 
 After evacuation, and thorough wiping of the abscess walls with 
 iodoform gauze, the wall of the abscess ca\'ity and the structures of 
 the abdominal wall are sutured in layers. A psoas abscess does not 
 admit of such secure closure, after evacuation just below Poupart's 
 ligament; but the abscess wall, the fascia lata, and the skin usually 
 can be closed in separate layers. A lumbar abscess is approached as 
 in operations on the kidney, and usually the abscess wall, the lumbar 
 fascia, and the skin, can be sutured separately. 
 
 If the abscess is giving no symptoms, does not tend to enlarge, and 
 is not so near the skin as to make probable the occurrence of secondary 
 infection from skin cocci, it should be left alone, and the patient should 
 be treated as if it did not exist. Constant watch, however, should be 
 kept, and proper treatment promptly adopted whenever required. 
 
 It seems unnecessary to add anything as to the treatment of sinuses 
 to what was said in Chapter XV. 
 
 Treatment of Contractures. — Often recumbent treatment, with 
 weight extension applied first in the axis of the deformity, will allow 
 contractures gradually to be overcome. Occasionally tenotomies are 
 required (adductors, psoas, rectus femoris, tensor fasciae femoris, ham- 
 strings, tendo Achillis, etc.). But in many cases which have been 
 neglected, sinuses exist, with secondary infection; amyloid degener- 
 ation of the viscera is present; and nothing remains but to alleviate 
 the patient's miserable state until death ends the scene (Fig. 243). 
 
 Treatmetit of Paraplegia. — In almost every case in childhood recum- 
 bency will cause disappearance of paraplegia in the course of six 
 months or a year. In such cases, then, it is only after the failure of 
 such treatment that the question of operation need be raised. In 
 adults, also, recumbency in most cases will cause return of power 
 within that time. If after eight months or a 3'ear of recumbent treat- 
 ment in adults no improvement is noticed and spasticity still persists, 
 I think laminectomy (p. 601) should be done, and the tuberculous 
 granulation tissue excised; the dura should not be opened, as tuber- 
 culous meningitis probably would ensue; and it is quite useless, and 
 perhaps not always harmless, to curette away carious bone from the 
 vertebral bodies. Only when the paraplegia is of suddeji onset do I 
 think laminectomy should be undertaken as an early operation. 
 In ordinary cases the symptoms come on very gradually, and the 
 ultimate complete or nearly complete recovery, even after many 
 months of complete abolition of the motor functions, is due to this 
 very feature, as the cord gradually accustoms itself to the condition 
 of pressure. But when the onset is sudden or very rapid (complete 
 paraplegia developing in a few days in a patient previously not even 
 spastic), the cord has not the time to so accustom itself, and there is 
 
INFECTIOUS SPOXDYLITIS (US 
 
 ^Tcat (lan<jc'r that it may be flamafi;e<l irretrievably unless the pressure 
 is promptly relieved. In eases with such rai)i(l onset, as already' noted, 
 it is probable that the cause is rupture of an absecss int(» the sjiinal 
 canal. 
 
 Other Forms of Infectious Spondylitis. — Tyyhoid Spondylitis 
 was referred to at p. 473. When a patient has lain long in bed, with 
 any wasting disease, his spine is apt to become affected from static 
 strain; lying ffat on the back, the normal lumbar lordosis may be 
 lost, and the thoracic kyphosis may be increased. As a consequence, 
 when he first assumes the erect i)osture, or even during convalescence 
 in bed, complaints of stiff' back may be made. This condition is not 
 very infrequent after long and serious attacks of typhoid fever, but 
 though it is called colloquially by the name of "typhoid spine," it 
 should not l)e confused with true typhoid spondylitis. The latter 
 condition is much rarer, and is due, as suggested in 1889 by Gibney, 
 and as demonstrated in 1900 by McCrae, to definite lesions in the 
 vertebrae, similar to those occurring in the long bones as a sequel to 
 typhoid fever (p. 425). Only a few vertebrae are involved, usually 
 in the lower thoracic or lumbar region. The onset is very acute, 
 resembling the most severe cases of Pott's disease, with great pain, 
 which may radiate along the spinal nerves, and perhaps with cramps 
 in the extremities. Any motion is painful. Sometimes a kyphos 
 develops. Treatment is the same as for tuberculous spondylitis; 
 though ankylosis may result, recovery usually is complete in a few 
 months. 
 
 The spine maj' be affected also by gonococcic and pneumococcic 
 infection, as w^ell as by that due to injfluenza, tonsillitis, etc. The 
 symptoms are subacute in onset, are typical of an infectious as 
 distinguished from a dystrophic process (p. 452); and the diagnosis 
 depends on the recognition elsewhere in the body of the original 
 infective focus. According to Painter, the entire vertebral column, 
 or the greater part of it, is affected at once, the lesions not being con- 
 fined to any one region, as is so frequently the case in hypertrophic 
 arthritis of the spine. There is spinal rigidity, but not much deformity, 
 unless this be a slight lateral deviation, or inclination to round 
 shoulders. From involvement of the costal articulations, respiration 
 is hampered. Treatment implies cure of the infecting focus, whenever 
 this can be discovered, with support to the spine during the period 
 of acute symptoms, and counter-irritation, massage, and gymnastics 
 at a later date. The spine may also be affected by what were 
 described in Chapter XV as Subpyemic and Cryptogenous Infections. 
 (See below.) 
 
 Dystrophies of the Vertebral Column. — These affections conform 
 more vr less closely to the tw^o main types of dystrophic arthritis 
 discussed in Chapter X^^ The term Spondylitis Deformans is quite 
 as indefinite as is arthritis deformans, since it may include both types, 
 or be limited, as it is by some, to the hypertrophic form. 
 
 In atrophic spondylitis the vertebrae seldom if ever are affected unless 
 
616 
 
 SURGERY OF THE SPINE 
 
 the small peripheral joints have been attacked previously; the spinal 
 changes, therefore, occur merely as an advanced stage of atrophic 
 arthritis as described at p. 452. Fig. 654 depicts the typical attitude 
 assumed by these patients. Great care should be exercised to exclude 
 any infectious origin for stiffness of the spine, before presuming to 
 make a diagnosis of atrophic spondylitis. In what have been described 
 as the subpyemic and cryptogenous infections, the vertebral column, 
 when affected, seldom presents the rounded kyphosis (Fig. 654) which 
 characterizes the dystrophic conditions; usually it becomes abnormally 
 straight, and the patient often has been described as having a " poker- 
 back." The treatment of atrophic spondylitis has been discussed 
 suffif^'iently in connection with atrophic arthritis (p. 456). 
 
 Fig. 654. — Atrophic arthritis of 
 spine ; age sixteen j-ears ; duration one 
 year. Fingers, right knee, and left 
 shoulder are involved also. Ortho- 
 paedic Hospital. 
 
 Fig. 65.5. — H\"pertrophic spondylitis; in- 
 volvement also of acetabulum and pelvis. 
 From a specimen in the Miitter Museum of 
 the College of Physicians of Philadelphia. 
 
 In hypertrophic spondylitis, the spine may be affected alone, or in 
 association with one or more of the larger joints of the extremities. 
 As in hypertrophic arthritis affecting such joints alone, so in the 
 vertebral disease, a history of previous trauma or of actual static 
 strain usually may be obtained. As a rule only a limited portion of the 
 vertebral column is affected, especially the lumbar region, frequently 
 in conjunction with hypertrophic arthritis of the sacro-iliac or 
 
INTRASPINAL TUMORS 617 
 
 hip-joint of one side. The pathological changes closely resemble those 
 onconntcrcd in the joints of the limbs, and exostoses or osteophytes 
 frcciucntly may be detected in skiagraphs. Early in the disease there 
 is softening of the vcrtcl)ral bodies (rarefying osteitis), and considerable 
 <leformity may occur, in the form of a more or less rounded kyphosis. 
 As the affection progresses, however, the new-formed periosteal out- 
 growths tend to cover the vertebral bodies with a more or less con- 
 tinuous bridge of bone, rendering the spine absolutely inmiobile (Fig. 
 (555). Usually this bony coating is situated to one or other side of the 
 median line, antl there may be a corresponding lateral deviation of the 
 spinal colunni. If any of the spinal nerves are compressed there may 
 be neuralgic pains in the parts supplied, and sometimes there are 
 secondary muscular atrophies. This complication was described by 
 Bechterew (1892) as a special type of the disease. When one or 
 more of the "root joints" {i. e., hip, shoulder) of the limbs were 
 involved in the hypertrophic changes, the affection was considered 
 by j\Iarie (189S) a separate disease, and was described by him as 
 "spondylose rhizomelique." In many cases of hypertrophic spondy- 
 litis the affection progresses so quietly that the patients never apply 
 for treatment, and the deformity is discovered by incident or only 
 at autopsy. In others, pain, stifl'ness, and considerable disability 
 demand relief. Treatment is to be conducted as in cases where other 
 joints are involved in hypertrophic arthritis (p. 459). 
 
 Intraspinal Tumors. — Usually these are small, more or less encapsu- 
 lated growths, springing from the meninges, and intradural in location 
 nearly as often as extradural. Very rarely has an intramedullary 
 tumor been found. In most of the reported cases the tumors were 
 sarcomatous, but fibroma, endothelioma, echinococcus cysts, and other 
 growths have been found; and it is not unlikely that in some of the 
 cases classed as sarcomatous the microscopical diagnosis was in error. 
 
 Symptoms. — Pain of a rheumatic or neuralgic character, localized 
 to one limb or to one of the intercostal nerves, usually is the first 
 symptom. This pain may subside under treatment but is prone to 
 recur, and after a few months or even years is accompanied by a 
 numbness or heaviness in the affected extremity. Though unilateral 
 at first, the symptoms nearly invariably become bilateral before 
 complete paralysis develops. The ensuing paraplegia conforms to 
 the ordinary type due to "pressure myelitis;" there is spasticity at 
 first, but later complete flaccidity develops. As physical signs of a 
 tumor (deformity, rigidity of the spinal muscles, tenderness) usually 
 are absent, the diagnosis depends largely on the history, on the slowly 
 developing paralysis, and on exclusion of other forms of medullary 
 compression. A neurological consultation is desirable to aid in deter- 
 mining the spinal segment involved. It scarcely ever is possible, to 
 determine before operation the nature of the tumor, whether or not 
 it is extradural, or even whether or not it is intramedullary. 
 
 Treatment. — Immediate resort should be had to laminectomy when 
 once the diagnosis is reasonably certain, as the prognosis is absolutely 
 
618 SURGERY OF THE SPINE 
 
 bad unless pressure on the cord is relieved. The usual mistake, on 
 the part of both neurologists and surgeons, has been to expect to find 
 the tumor at too low a level. Hence the surgeon should expose first 
 that region of the cord which is supposed to be affected; and if the 
 growth is not found there, he should search upward until the cause of 
 compression is found. In 1905 I collected for Ilarte records of 92 
 operations for intraspinal tumor; in only 5 of these cases did the 
 surgeon fail to find the tumor, and in three of these it was learned 
 subsequent!}' that it was situated only a very little higher than the 
 region exposed at operation. Elsberg has pointed out that in some 
 cases where an intramedullary or subpial tumor cannot be removed 
 at the primary operation, it will be found to have been spontaneously 
 extruded a few days later. 
 
 The mortality of the operation has been about 25 to 30 per cent., 
 but is less in more recent times. Of those patients who survived 
 nearly 60 per cent, were classed as cured; 34 per cent, as improved; 
 and in only 6 per cent, was no improvement secured. 
 
 Chronic Serous Spinal Meningitis usually is a complication of 
 chronic serous cerebral meningitis (p. 579), but ma}' occur indepen- 
 dently (Krause, 1906), as a localized collection of serous fluid, possibly 
 the result of a previous infection which has caused adhesion of the 
 pia to the dura over a limited area (Spiller, 1906). It produces 
 symptoms closely resembling those of intraspinal tumor, and the 
 treatment is the same. 
 
CHAPTHR XIX. 
 STTRCEPvY OF THE FACE, MOUTH, AND NECK. 
 
 SURGERY OF THE NOSE. 
 
 Epistaxis or Nosebleed may occur spontaneously or from trauma. 
 Probably manv cases of nosebleed thou^dit to be spontaneous really 
 are due* to slight trauma, in "blowing" or "picking" the nose. 
 Hicrh arterial tension, from renal or cardiac disease, is a predisposing 
 cause The patient should lie flat with the head slightly elevated, 
 and should refrain from blowing the nose. It should not be thought 
 that hemorrhage has ceased merely because no blood runs out ot the 
 nostril, since the patient may be swallowing the bloo( as it runs 
 backward into the pharynx. Later such blood may be vomited. 
 Cold applications are efficient in checking the hemorrhage in most 
 case« It often is possible to check bleeding temporarily by raising 
 the arms above the head, thus diminishing the venous pressure; but 
 bleeding mav recur when they are lowered. A hot mustard toot bath 
 may be tried. Applving a small roll of gauze between the upper ip 
 and the alveolar process, in the midline, and compressing the lip 
 over this pad, sometimes will control the bleeding by pressure on 
 the coronarv vessels of the lip or the arteria septi nasi. In almost 
 every case the bleeding comes from this artery as it travels upward 
 along the cartilaginous septum just within the nostril. By raising 
 the tip of the nose, and with light reflected from a head-mirror it 
 often is possible to see this bleeding-point, especially it the nostril 
 is sprayed with cocain solution (2 per cent.) or swabbed with 
 adrenalin (1 to 1000). These agents, or hydrogen peroxide, fre- 
 quently are effective in checking the hemorrhage. If bleeding per- 
 sists, and as a last resort, the tampon must be resorted to. It a bimp- 
 son splint (made of Bernays's sponge, which when moistened swells 
 to eio-ht times its previous size) is available, it may be inserted within 
 the nostril, and usually is very efficient. If bleeding occurs from further 
 back in the nostril, it may be necessary to plug the posterior as well 
 as the anterior nares. This is done by attaching a string to the end 
 of a soft rubber catheter, and passing this (string end first) along the 
 floor of the nostril until the catheter emerges in the pharynx; both 
 ends of the string are then pulled out through the mouth, and to one 
 end is tied a tampon of size sufficient to plug the posterior nans ot the 
 bleeding side (Fig. 656). As the catheter is withdrawn from the nose 
 this tampon is pulled by the string into the mouth, around the pos- 
 terior margin of the soft palate and into the posterior nasal opening. 
 The other end of the string is left long, hanging from the mouth, to 
 
620 
 
 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 Fig. 656. — Plugging the posterior nares. 
 
 facilitate withdrawal. The anterior naris is then plugged from the 
 front. These tampons should not be left in place more than twenty- 
 four or thirty-six hours, as they are apt to excite suppuration, and 
 
 perhaps maxillary or frontal sinu- 
 sitis, or even otitis media. A can- 
 nula expressly for plugging the 
 posterior nares was invented by 
 Bellocq, and is useful if at han(l. 
 Foreign Bodies in the Nose usu- 
 ally may be extracted b}' fine for- 
 ceps or scoop, under good illumi- 
 nation. If, however, the foreign 
 body lie not on the floor of the 
 nose, nor anteriorly, it will be 
 easier and safer to dislodge it by 
 s}Tinging warm boric acid or saline 
 solution through each nostril alter- 
 nately. 
 Acne Rosacea. — Acne rosacea in its early stages, comes under 
 the care of the dermatologist; but when through long duration and 
 neglect of proper treatment the skin and subcutaneous tissues of the 
 nose have become hypertrophied (Acne Hypertrophica, Rhinophyma), 
 then surgical treatment is necessary for a cure. The nose is now 
 enlarged, erythematous, covered with dilated venules or arterioles; 
 and nodules of various sizes and shapes make the patient conspicuous 
 (Fig. 657). Treatment: Frequent steaming 
 of the parts, after application of green soap 
 or a soap poultice, or ointments containing 
 sulphur or salicylic acid, may somewhat 
 improve the nutrition of the skin; but in 
 most cases the over-growths require to be re- 
 moved. Simply shaving ofi' these excres- 
 cences may suffice, the denuded areas being 
 left to heal by granulation ; or excision may 
 be done, and the wound covered with 
 Wolfe skin grafts. 
 
 Rhinoplasty. — The formation of a new 
 nose, wholly or in part, may be required for 
 various reasons. The deformity known as 
 Saddle Xose (Fig. 937), occurring as the 
 
 result of syphilis, old fracture, or other lesion, may be remedied by 
 implanting beneath the skin a suitably shaped bridge of silver or 
 bronze-aluminum. Subcutaneous injections of paraffin have also been 
 employed. Kolle uses paraffin with a melting-point of 102° to 115° 
 F., and makes the injections (by means of a special syringe with a 
 screw piston) with the paraffin cold; this obviates danger of embolism. 
 No anesthetic is required if the injection is made slowly, anrl if only 
 a small quantity is injected at any one time. 
 
 Fig. 6.57. — Rhinophyma, or 
 hammer nose. (Tillmanns.) 
 
SURGERY OF THE NOSE 
 
 621 
 
 If tlic nose is i-omplctely destroyed from injury, lupus, syphilis, 
 etc., a new one may be constructed by plastic operations. In the 
 Indian inrthnd of rhinoplnsfy, used by the native surj^eons of India 
 for many centuries, and introduced into England in 181G by Carpue, 
 a fiaj) is taken from the forehead, and is twisted around a pedicle 
 wliich contains the angular, frontal, and supraorbital arteries of one side 
 (Fig. (io8). The flap is made a quarter of an inch larger on all sides 
 than desired, as it is sure to shrink. The edges of the nasal opening are 
 then freshened, and all bleeding is controlled by very fine catgut liga- 
 tures. The frontal Hap is then rotated and is sutured in place by tongue 
 and groove sutures (Fig. 059). A columna may be formed from the 
 upper lip, if thought desirable, after a week or ten days, but usually the 
 orifice of the new nose contracts so much that it is undesirable to sub- 
 divide it. The pedicle is not cut through for about a month after the 
 primary operation. The denuded frontal area may be left to heal by 
 
 granulation or may be covered 
 by Wolfe grafts. C. Nelaton 
 and Ombredonne (1904) intro- 
 duced a valuable modification 
 of the Indian method, in which 
 a piece of the eighth costal 
 cartilage is first transplanted 
 
 Fig. 658. — Outline of frontal flap for rhino- 
 plasty by the Indian method. 
 
 Fig. 659. — Tongue and groove 
 sutures. 
 
 beneath the skin of the forehead. Six weeks later the flap con- 
 taining this cartilage is cut and turned down over the nose. A 
 cutaneous lining for the nose is also formed by inverting a small flap 
 from the glabella and another from each side of the nose. The Italian 
 Method of lihinojjlasty, widely employed by Taliacotius in the sixteenth 
 century, consists in transferring a flap from the arm. At the first 
 operation the flap is marked out and is par+ially detached; when it 
 is sufficiently vascularized and thickened, after the lapse of about ten 
 days, this flap is stitched to the freshened edges of the remaining 
 nasal structures, and the arm and head are securely bandaged together. 
 A plaster of Paris dressing is desirable. About ten days or two weeks 
 later the flap is cut away from the arm; and a columna may be formed 
 then, or sub.sequently. 
 
 Rhinoplasty has also been done by transplanting a phalanx of the 
 finger or toe, or a piece of costal cartilage, into the subcutaneous tissues 
 of the nose; but such methods are applicable only when there is suffi- 
 
(522 
 
 SURCKUY 01' THE FACE, MOITJJ, AXD NECK 
 
 ciciit liealtliy skin already over the nose to ensure complete hnrial 
 of the transplantcfl structure. The "transplant" must he hrouf^ht 
 into contact with hone denuded of periosteum, so that the Haversian 
 systems extending from this may permeate the transplant fp. oiJo). 
 
 Fig. 660. — -Patient with destruction of 
 the nose. Before rhinoplasty. (See Fig. 
 661.) 
 
 
 ^ 
 
 ^ 
 
 -V *^ J 
 
 
 j^H 
 
 
 %,M 
 
 Fk;. 661. — Same patient after rhino- 
 Ijhisty hy the Indian method by the late 
 Prof. Ashhurst, 1894. University Hos- 
 pital. 
 
 SURGERY OF THE CHEEKS. 
 
 Keratosis Senilis or Seborrheic Patch has been referred to in Chap- 
 ter W as a j)recancerous coiiditioii of the skin. The skin of the face 
 of elderly persons, especially those who have been exposed much to 
 the weather, may present a number of slightly raised, greasy, yellow- 
 ish-})rown patches, due to hypertrophy of the epidermal cells, and 
 accumulation of sebaceous matter on the surface. If these patches 
 are picked ofi' ami a small bleeding erosion is revealed, this lesion 
 probably is a superficial epithelioma; if no bleeding occurs the lesion 
 may still be in its precancerous stage. Be>'ond recognizing this fact 
 ancl acknowledging the possibility that proper treatment by a skilled 
 dermatologist might i)revent or at least delay the (le\'clopment of 
 epithelioma, neither pathologist nor clinician can go. Before there is 
 any suspicion of malignancy, careful treatment of the skin should be 
 adopted. The face should be well steamed over a bucket of hot 
 water, at least once daily; after thoroughly' drying, a little salicylic 
 acid ointment (10 grains to the ounce) should be rubbed into the 
 seborrheic patches. Sometimes green soap (Tinctura Saponis \'iridis, 
 U. S. P.) should be used instead of ordinary toilet soap. D. W. Mont- 
 gomery, who has studied these cases most carefully, wipes ott' the skin 
 with glacial acetic acid, and in rebellious cases uses trichloracetic 
 
SURdEh')' OF rill-: CIIKI'JKS 
 
 023 
 
 acid, alter turcttiiiK the le.su)ii; then the .f-rays are eiiiph)\e(L He 
 l)()in'ts out that wlieii the cheeks or other portions of the face are 
 widelv alVected radical excision is not to he considered even if the 
 
 iy¥—)^-^t^r- 
 
 Y ^^ yj^k^^Y Y Y 
 
 Fig. 662. — Typical plastic operations. 
 
 epithehomatons nature of the lesions is recognized; and any flaps 
 used to repair defects left hy partial excision will themselves be the 
 seat of these precancerous growths, and will in time develop mto 
 epithelioma, causing an apparent local recurrence. If only one or 
 
(i24 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 two patches exist, they should be treated by excision, as in fully 
 developed epithelioma. 
 
 Superficial Epithelioma or Rodent Ulcer occurs more often on the 
 cheeks or forehead than any other part of the face, especially near the 
 ala nasi, on the lower eyelid, or near the angle of the mouth. Some 
 authorities claim that it owes its comparatively benign character 
 to the poverty of these areas in lymphatic vessels. Its pathology and 
 clinical course have been discussed in connection with tumors, (p. 123). 
 The question of diagnosis is important. It must be distinguished 
 from deep-seated epithelioma, lupus, and syphilis. Deep-seated 
 epithelioma rarely occurs on the face except on the lower lip; it 
 may develop from a seborrheic patch, but it is much more rapid in 
 growth than the superficial form (months instead of years), and 
 invades the regional lymph nodes. Lupus usually affects young adult 
 patients of scrofulous diathesis; it is very rare in those past middle 
 life in whom epithelioma is common; it almost always presents evi- 
 dence of having healed at some part, which is rarely the case in epithe- 
 lioma; and the typical apple-jelly nodules usually can be discovered 
 around the periphery of the ulcerated areas (p. 263). The facial lesions 
 of syphilis, especially ulcerated gummas, sometimes are mistaken 
 for epithelioma; but the previous history of the patient, the presence 
 of syphilitic lesions or their traces elsewhere in the body, the cir- 
 cinate or reniform shape of the ulcers, their greater depth and much 
 more rapid extension, as well as the result of antisyphilitic remedies, 
 and the presence of the Wasserman reaction, will render the correct 
 diagnosis evident. It should not be forgotten, however, that malig- 
 nant changes may develop in old syphilitic or lupous ulcers. 
 
 Treatment. — Treatment of rodent ulcer consists in excision of the 
 entire thickness of the cheek down to mucous membrane or bone. 
 The wound is then repaired by sliding flap as indicated in the accom- 
 panying diagrams (Fig. 662), or by Wolfe grafts. When it has been 
 necessary to sacrifice the mucosa also, the defect in the cheek may be 
 repaired by taking a pedicled flap from the neck and adjusting it in 
 place with its skin surface toward the cavity of the mouth. The 
 operation of repairing a defect in the cheek is known as meloplasty. 
 
 SURGERY OF THE SALIVARY GLANDS. 
 
 Infectious Parotitis, called also symptomatic parotitis, and parotid 
 bubo, is an acute bacterial infection of the parotid gland occurring in 
 the course of some general infection (typhoid fever, scarlatina, pyemia, 
 etc.). In rare cases the submaxillary or sublingual glands are similarly 
 affected. In contradistinction to epidemic parotitis (mumps), only 
 one parotid usually is affected, and suppuration is frequent. Cases 
 of this nature may also follow abdominal or other operations, but 
 rarely, if ever, unless general anesthesia has been induced. In all 
 such instances, as in typhoid fever and other wasting diseases, there 
 is abundant opportunity for a direct ascending infection from the 
 
SURGERY OF TIJK SALIVARY GLANDS 02.") 
 
 moiitli alonfj; vStcnson's duct; and while infection through tlic hlood- 
 streani cannot he deniech it prohahly is rare. In the suhstance oF the 
 parotid ghuid, l)et\veen its h)hules, there are numerous minute lymph 
 nodes; and it is possible that some cases classed as parotitis really are 
 instances of lymphadenitis of these nodes. Prophylaxis is important, 
 and consists in measures to promote cleanliness of the mouth and 
 prevent drying of the nuicosa around the orifice of the })ar()tid duct. 
 Mechanical injury of the glands should he avoided during anesthe- 
 tization. 
 
 Treatment. Local api)lications (ice bag, painting with iodin, mouth 
 washes) may be useful before suppuration occurs. This should be 
 treated i)romptly by incision parallel with the branches of the facial 
 nerve. A probe is then inserted, and an endeavor made to secure 
 drainage of all pockets of pus through the one opening; but owing to 
 the dense fibrous stroma of the gland each suppurating lol)ule may 
 ha\e to !)c incised separately. 
 
 Tuberculosis sometimes attacks the parotid lymph nodes, but very 
 rarel}^ affects the glaiid itself. Excision of these nodes is difficult 
 without injuring the facial nerve. 
 
 Tumors of the Parotid. — The peculiarity of parotid tumors is that 
 they usually are of the "mixed" variety (p. 106). This may be due 
 to the situation of the parotid in the region of the first branchial cleft 
 of fetal life. These tumors are very apt to contain cartilage, with 
 areas of myxomatous degeneration; rareh' cysts may form. They 
 occur in young adults, and grow with extreme slowness; often no 
 change is appreciable from year to year (Fig. 063). At first they are 
 fairly well encapsulated, but owing to the def^p relations of portions 
 of the parotid gland, they appear to be fixed at an early stage of 
 deAclopment. Though the tumor may grow to an immense size, the 
 facial nerve seldom is affected; but the lobe of the ear becomes dis- 
 placed, outward and upward. If rapid growth develops, as it usually 
 does in time, malignancy should be suspected (Fig. 664). In very 
 advanced cases, secondary enlargement of the cerA'ical lymph nodes 
 may occur. Similar growths may occur in the submaxillary salivary 
 f/hnids, but are much rarer, and seldom are distinctly cartilaginous. 
 
 Treatment. — If the patient is seen before the tumor is large, and 
 before rapid growth has commenced, it often is possible to enucleate 
 the growth from the substance of the parotid without injury to the 
 facial nerve or Stenson's duct. Operation should be urged before the 
 tumor grows very large. The incision should be made parallel with 
 the branches of the facial nerve, nearly as high as the zygoma, and 
 the knife should pass at once to the tumor, with no dissection of the 
 superficial structures, as this is apt to injure the facial nerve. The 
 growth is then enucleated, and the wound closed by buried and super- 
 ficial sutures. In malignant cases wide-sweeping excision must be 
 practised if any operation is undertaken, but an attempt should be 
 made to preserve the facial nerve by exposing its main trunk before 
 it enters the tumor. Preliminary ligation of the external carotid 
 40 
 
626 
 
 SURGERY OF THE FACE, MOCTII, AXD XECK 
 
 artery often is advantageous. Blunt dissection should be avoided. 
 The parts should be freely exposed, and nothing should be cut that 
 cannot be seen. The operation is tedious, difficult, and dangerous. 
 If the tumor extends far into the retro-maxillary fossa and appears 
 densely adherent there, as ascertained by preliminary examination 
 through the mouth, usually no operation should be done. (See also 
 remarks on Excision (jf Tumors, p. 131). 
 
 HIPH 
 
 ^B ^^^^H 
 
 
 ^^^^Bjj! --.... ^O- __^^^^^M 
 
 ^^^ ' >MH 
 
 Fig. 663.— Mixed tumor of parotid, age 
 forty-two years; duration twenty-two 
 years. Verj- slow growth. Episcopal 
 Hospital. 
 
 Fig. 664. — Mixed tumor of parotid 
 (sarcomatous;; twenty-one years' dura- 
 tion. Weight of tumor two pounds. Re- 
 moved by the late Prof. Ashhurst, 1896. 
 University Hospital. 
 
 Mikulicz's Disease (1892) is a rare affection characterizerl by pain- 
 less, slowly (le\'eloping, chronic, symmetrical enlargement of the 
 parotid and lachrymal glands; sometimes the sul)maxillary and sub- 
 lingual glands are involved also. In some cases there is general lym- 
 phatic involvement and enlargement of the spleen. There may be 
 fever. If such constitutional remedies as arsenic and iodide of potash 
 are ineffectual, extirpation may be justifiable for cosmetic reasons, 
 or to relieve pressure on neighboring structures. The cause of the 
 disease is unknown. 
 
 Salivary Fistula. — This usually arises in the parotid gland, especi- 
 ally in its main duct, as the result of injury (operative or accidental) 
 or suppuration. The secretion discharges on the cheek which is kept 
 constantly moist, especially while food is being masticated. The skin 
 may become very much irritated. The mouth feels dry. The patient 
 is rendered both conspicuous and miserable. 
 
 Treatment. — If the orifice is in front of the masseter muscle the 
 fistula is not so difficult to cure. A cannula may be passed from the 
 mucous surface of the cheek through the fistula on to the cheek where 
 it makes two punctures, about one centimeter apart; a fine wire (of 
 silver, iron, or bronze-aluminum) is then passed through these two 
 
SUlUiEUY OF Tlll<: SALIVARY (iLA.\US 
 
 ivi: 
 
 artificially iiKuk- niiicous orifices (Fi^'. ()(').")), and is tied on the mucous 
 surface (Fiji;. (KiO). The edges of the cutaneous orifice are then fr<'sh- 
 ened, and it is closed by suture. The parotid secretions then find 
 their \v;i\ aiong the wire to the mouth, and. by the time the wire cuts 
 
 out and establishes an internal 
 opening the cutaneous orifice has 
 healed. If the fistula is situated 
 over the masseter muscle, at- 
 tempts should be made to con- 
 struct a chaimel forward in the 
 cheek to its anterior edge, either 
 
 ^ , ^ ^^^-==^ Mucosa 
 
 Sa/ira/y duc^ 
 
 
 Fiii. 005. — Operation for salivary fistula: 
 both ends of a wire are conducted to the 
 mucous surface of the cheek through punc- 
 ture made by a cannula. 
 
 C'utaneo/js opc/ii//^ off/s/ula 
 
 -Skin 
 
 Fig. 666. — Operation for .salivary fis- 
 tula: the wire is tied on the mucous sur- 
 face. 
 
 by establishing a seton, as in the method just descrif)ed, or by a 
 formal i)lastic operation. Occasionally partial excision of the parotid 
 gland will be necessary to cause cessation of discharge. If no infection 
 is i)resent, simple ligation of the main 
 (fuct on the central side of the fistula 
 may result in atrophy of the gland. 
 
 Sialo-lithiasis or Salivary Calculus 
 is not a very uncommon condition. In 
 1908 Bendixen referred to 216 cases. 
 The calculous formation is due to 
 bacterial action on the secretion of the 
 glands, as in the pathogenesis of biliary 
 calculi. The calculus usually obstructs 
 the excretory duct, causing secondary 
 enlargement of the glands, with mild 
 inflammatory symptoms. Occasionall\- 
 recurrent attacks of colic occur. The 
 affection is much more common in the 
 submaxillary than in either the parotid 
 or sublingual gland. Often the calcu- 
 lus is palpable in the floor of the 
 mouth, just beneath the mucosa. 
 Treatment consists in removal of the 
 stone by incision in the floor of the 
 
 mouth; if the calculus is in the body of the gland, and especially 
 if there is suppuration or a cutaneous fistula, it is better to excise the 
 entire gland, by an incision beneath the mandible. 
 
 Chronic Inflammation may affect the submaxillary and sublingual 
 salivary glands. The affection may simulate a neoplasm in its gradual 
 
 Fig. 667. — Chronic inflammation 
 of submaxillary and sublingual sali- 
 vary glands and of submaxillary 
 lymph nodes. Episcopal Hospital. 
 
C)28 
 
 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 onset and indolent course. Usually the glands are found to contain 
 minute abscesses, and there is increase in the connective tissue. Extir- 
 pation is the proper treatment (Fig. 667). 
 
 SURGERY OF THE EAR. 
 
 Foreign Bodies. — It is necessary first to ascertain whether or not the 
 foreign body still is present. In children the history is not always very 
 clear, and much harm may be done by incautious exploration. If a 
 probe or forceps is pushed blindly along the canal, the foreign body 
 may be driven further in. Under good ilhmiination from a head-mirror, 
 and by drawing the pinna upward and backward to straighten the 
 external auditory canal, the surgeon will be able to detect the presence 
 of a foreign body (Fig. 668). In children the use of an ear speculum 
 seldom is necessary, but where the canal is hairy, as in many adults, 
 this is indispensable. In most cases persistent syringing with warm 
 sterile saline solution or weak antiseptic will be successful in remov- 
 ing the foreign body; but if this is a pea or bean the soaking may 
 cause it to swell up and thus render its removal more difficult. For 
 such bodies, therefore, and for all others where syringing has failed, 
 delicate forceps or scoop should be employed. The same methods 
 should be employed in cases of impacted cerumen. 
 
 Sy^m^ 
 
 
 Fig. 668. — Examination of external auditory canal bj- light reflected from a 
 
 head-mirror. 
 
 Furuncle. — Furuncle of the auditory canal is an exceedingly painful 
 condition which requires prompt incision. Even though the sharpest 
 knife is used, and the incision made with great delicacy, the pain is 
 excruciating, but if the auriculo-temporal nerve, just in front of the 
 tragus, is infiltrated with a few drops of a 2 per cent, novocain solution 
 complete anesthesia is secured (Skillern, 1913). After opening, the 
 crater of the furuncle should be touched with a drop of tincture of 
 
SURGERY or Till' EAR 
 
 629 
 
 Fig. 669. — Proper incision to 
 evacuate an othematoma. 
 
 iodiii or i)iir(' carholic acid; and a small plcdj^'ot of cotton slionld l)e 
 iiitrodnccd, and an ast'ptic dr('ssin<^ then l)an(laji;ed to the auricle. 
 
 Hematoma Auris or Othematoma nsually is the result of a blow. 
 It i.s not unconunon in patients in insane asylums, who can ^ive no 
 account of its api)earance; and on this account it has been thought 
 to have some occult connection with un- 
 soundness of mind. If it ever develops 
 spontaneously, it probably is to be attrib- 
 uted to arterio-sclerotic changes. The 
 eH'used blood separates the skin from the 
 cartilage, usually over the pinna; and 
 unless proper treatment is instituted the 
 auricle will become conspicuously deformed 
 from organization and cicatrization of the 
 thrombus. Tlie blood may be aspirated 
 by a hypodermic needle in very recent 
 cases; but usually the blood is semi-clotted, 
 and an incision is necessary. This should 
 be made along the helix (Fig. GG9), and 
 after the blood is evacuated the skin should 
 
 be reapplied very carefully to the underlying cartilage and should lie 
 held against it by accurate adjustment of small pads and a firm l)and- 
 age. Unless this coaptation is very firm and exact, re-accumulation 
 of blood will occur. After a few days massage should be employed. 
 
 Prominence of the Auricle, either congenital or acquired, may be 
 remedied by suitable plastic operation. In the usual congenital form 
 the pinna hangs down like a hood, and the condition is named " lop- 
 ear." Generally it is sufficient to remove an ellipse of skin from the 
 posterior surface of the auricle and adjoining scalp, and then to suture 
 the ear against the head and keep it in place by a firm bandage. Some 
 such support should be worn for several weeks. Occasionally it is 
 necessary to excise some of the cartilage of the auricle also. 
 
 Supernumerary Auricles are not very rare. Excision is the proper 
 treatment. 
 
 Otitis Media. — The middle ear is a mucous-lined cavity, draining 
 into the pharynx through a long and narrow channel, the Eustachian 
 tube. Infection usually ascends from the pharynx, which often is 
 septic, especially if adenoids are present. Occlusion of the Eustachian 
 tube or of either of its orifices renders the middle ear a closed chamber 
 where microbes are prone to multiply and increase in virulence. The 
 middle ear in these respects resembles the \ermiform appendix. In 
 cases of middle-ear disease or its complications, the services of an 
 otologist are desirable; but as these cannot always be obtained in 
 emergency, the general surgeon may be called upon to treat the 
 acute stages of such lesions. Only emergency treatment, therefore, 
 is considered in this work. 
 
 Catarrhal inflammation of the middle ear frequently develops after 
 an attack of measles, pneumonia, scarlatina, or other infectious 
 
030 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 flisease. It is accoinpaiiicHl by ear-ache, sli<,flit deafness, a sense of 
 fulness in the ear, sH<i;ht feverishness, and i)r()})ahly some dxsjjha^ia. 
 Ins])eeti()n of the drum membrane, with reflected hj,dit, throu<:;h a 
 speculum, shows it reddened and swollen, and sometimes buljjiiif;, 
 especially in tlie posterior part. By moving the })atient's head back 
 and forth it may be ])ossible to see the undulation of fluid throu^rh the 
 semi-transparent drum membrane. Later the membrane becomes 
 opacpie. 
 
 In acute purulent inflammation of the middle ear the symptoms 
 are the same in kind though usually more severe in degree. The 
 afl'ection usually is purulent from the first, and does not follow 
 catarrhal inflammation. In children the afi'ection may run its course 
 almost without pain, although pressure on the tragus usually is painful, 
 as the bony canal is still incomplete, and movements of the auricle are 
 communicated to the middle ear. Often only a sudden rise of tempera- 
 ture will show any deviation from the normal. I'his is so frequently 
 the case in children that any sudden rise of temperature during con- 
 valescence from the exanthemas, influenza, bronchitis, etc., demands 
 examination of the ears. If such examination is neglected, the first 
 thing to attract attention to the ear may be the discharge of pus 
 following spontaneous perforation of the drum membrane. 
 
 Treatment. — Simple "ear-ache," which may be due to referred 
 pain from pharyngeal or dental affections, or may be a mild form of 
 catarrhal otitis media, usually may be relieved b>' instillation into 
 the external auditory canal of a few drops of hot water. This is quite 
 efficient as hot laudanum or other drug. It is the heat rather than the 
 drug that is effective. If there is evidence of accumulation of fluid 
 within the tympanic cavity, especially if there is any bulging of the 
 membrane, this should be incised (myringotomy) : after suitable clean.s- 
 ing of the canal by dilute hydrogen peroxide and aseptic syringing, 
 the incision is macle in a cur^•ed line around the entire posterior cir- 
 cumference of the drum membrane, thus forming a flap, which allows 
 much more free and prolonged drainage than a mere puncture. The 
 point of the knife should not do more than penetrate the membrane, 
 as the tympanic cavity may be very shallow\ The ear is drained by 
 a small strip of gauze extending just as far as the drum membrane; 
 this should be renewed as often as it becomes soaked with discharge — 
 several times an hour if necessary. Several times daily, not oftener 
 than every two or three hours, the canal should be irrigated 
 gently with a weak antiseptic solution. Heat to the mastoid will 
 be grateful, and sedatives may be requisite to allay the pain. The 
 patient must be confined to bed for several days. The nasopharynx, 
 whence the infection usually has come, should receive appropriate 
 treatment. 
 
 Acute Mastoiditis. — Invasion of the mastoid cells, by extension 
 of infiammation from the middle ear through the aditus and the 
 antrum, occurs in many cases of acute purulent otitis media. Prom])t 
 treatment of the' middle-ear disease by myringotomx' will permit 
 
SlfRGERY OF THE EAR 
 
 (VM 
 
 rec()\('r>' in many cases witliDUt pennaiiciit daiiiaf^c to the aiitriim 
 or mastoid. It' the discharjfo of j)us jxTsists Inii^f, and is profuse, in 
 s|)ite of pro|)er conservative treatment of the middle ear, it usually 
 indicates that there is involvement of the mastoid cells. This is a 
 chronic condition, however, and does not concern us here. Not infre- 
 (piently, shortly hefore s\inj)tonis of nriitr mastoiditis a])pear, an ear 
 which had i)cen "running'" for months or years suddenly ceases to 
 discharge. Tlie patient has pain in and l)ehind the ear; there is fever, 
 perha|)s chilliness or an actual chill; lieadache aiui general malaise. 
 The mastoid is tender, not only at its 
 tip, as sometiines occurs in cases of 
 simple otitis media, hut especially over 
 the emissary vein and the antrum; and 
 in some cases there is e\idence of peri- 
 osteitis. In children j)us often makes its 
 way outward alon<^ the petro-mastoid 
 suture, bulges beneath the periosteum, 
 and causes the auricle to stand away 
 from the head in a very characteristic 
 manner (Fig. ()7()). In rarer cases an 
 abscess forms deep in the neck beneath 
 the sterno-mastoid muscle (BezoIcVs 
 abscess). In adults movement of the 
 auricle is not painful; this is an impor- 
 tant differential sign from furunculosis 
 of the external auditory meatus. But 
 in children, in whom the bony canal is 
 
 less well developed, mo^■ement of the auricle is communicated to the 
 middle ear and hence usually causes pain. 
 
 Diagnosis. — This rests on the previous history of the case, namely, 
 onset of ear trouble usually in convalescence from an acute infectious 
 disease; on the existence, past or present, of chronic otitis media; 
 and on ])hysical examination of the ear, showing mastoid tenderness, 
 redness, and edema, perhaps with protrusion of the auricle. 
 
 Prognosis. — If the infecting organism is the staphylococcus or even 
 the pneiunococcus, recovery without operative treatment (other 
 than myringotomy) may occur in a fair proportion of cases. Where 
 the streptococcus or the Bacillus mucosus capsulatus is found, bone 
 destruction is apt to be much greater, and very seldom can operation 
 be avoided. 
 
 Treatment. — In cases which develop soon or immediately after the 
 first appearance of an otitis media, operation on the mastoid may be 
 delayed one or two days, to ascertain what effect the myringotomy 
 will have on the mastoid symptoms. But if the B. mucosus capsu- 
 latus is found in the discharge from the middle ear no delay in operating 
 should be permitted; operation should not be postponed even until the 
 next day. When the streptococcus is fountl delay never should be 
 longer than one week, even when clear signs of mastoiditis are 
 
 I II,. G7lJ. — Mastoid abscc.-^s 
 (left; pointing through petro- 
 mastoid suture. Age three and 
 a half years. (Dr. Gibbs'scase.) 
 Episcopal Hospital. 
 
632 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 lacking. Prom])t drainage of the infected bone is demanded. There 
 is great risk of sinus tlironibosis (p. 577) or l)rain al)scess (p. 579) if 
 there is delay, especially in cases occurring as exacerbations of long 
 standing middle-ear disease with inefficient drainage. 
 
 Operation for ^ic7itc Mastoiditis. — An incision is made from the tip 
 of the mastoid process upward, parallel with and about 5 mm. post- 
 erior to the attachment of the auricle, for a distance of two or three 
 inches. This incision passes directly to the bone, but as in children 
 the bone is very soft, great care should be taken not to cut too deeply. 
 If the posterior auricular artery is di\ide(l, it should be clamped and 
 ligated at once. The periosteum is then separated from the bone 
 throughout the length of the incision, for a space of nearly an inch 
 in width, exposing the posterior wall of the external auditory meatus, 
 and the siijjranicatal spine of Henle. The sternomastoid muscle is 
 
 Fia. 671. — Macewen's triangle, outlined on the skull; and the suprameatal 
 spine of Henle. 
 
 then detached from the mastoid tip, cutting it close to the bone. If 
 more room is required at any stage of the operation an incision is 
 carried backward from the centre of the post-auricular incision, and 
 the two triangular flaps so formed are elevated from the bone. The 
 surgeon next identifies the suprameatal triangle (Macewen, 1893), which 
 lies above and behind the external auditory meatus; it is bounded 
 in front by the bony wall of this canal and the suprameatal spine, 
 above by the posterior root of the zygoma, and posteriorly by a line 
 joining these two (Fig. 071). This triangle is the guide to the situa- 
 tion of the antrum, over which it lies. In children the antrum lies 
 at a higher level than in adults, in whom it is more behind than above 
 the meatus. Usually the bone directly covering the antrum is per- 
 forated by minute venous channels, and the antrum may be located in 
 this way. The antrum may be opened first (Fig. 672), as advised 
 by Macewen; or the surgeon may first remove the cortex overlying 
 
si'RCEin' or THE ear 
 
 (i.33 
 
 tlio niiistoid cells, iVoiii the tip of tlic mastoid up to the iiiitrimi. If 
 a dental (.'ii,i,niu' is a\ailal)k', a rotary hiirr is a wry satisfactory iiistru- 
 nu'iit. I siially, however, a ^ouf^o and mallet are used to remove the 
 cortex, and then the pneumatic cells are excavated by a bone curette 
 or fine ^ou^e forceps. In youn^ children a stronj^ curette will remove 
 the cortex also. The instruments should be made to cut from within 
 outward, unless the parts are fully exj)osed. The entire mastoid, 
 includiuff its tip, should be removed; and in most cases all the pneu- 
 matic cells which are accessi})le, wherever situated, should be removed, 
 inclu(lin<i; any in the posterior zygomatic root. As the pneumatic 
 cells may extend along the petrous portion of the tcm])oral bone even 
 to its apex, it manifestly is impossible to remove all in every case, 
 and in cases wlicr(> the patient is extremely septic it undoubtedly is 
 better merely to secure free drainage, and to leave the C()ni])lcti()n of 
 
 Fig. 672. — Operation upon the mastoid 
 antrum. The antrum (a) has been laid 
 open and gouged out, and the bridge of 
 bone (b) between it and the external audi- 
 tory meatus is seen. (Cheyue and Burg- 
 hard.) 
 
 Fig. 673. — Operation upon the mas- 
 toid antrum. A bent probe has been 
 introduced from the antrum to the 
 middle ear. (Cheyne and Burghard.) 
 
 a radical operation for another occasion. But in every case, without 
 exception, it is necessary to open the antrum, and thus accomplish 
 the purpose of the operation, the securing of free drainage of this region 
 of the middle ear through the mastoid. As the bone is being removed 
 it should be repeatedly examined by the probe; the antrum is recog- 
 nized by the probe passing first upward, then forward and inward 
 into the middle ear (Fig. 673). A probe introduced into the middle 
 ear through tlie jjerforated tympanic membrane may be an aid in 
 locating the antrum. 
 
 The structures in most danger of injury are the sigmoid siinis, 
 the facial nerve, and the horizontal semicircular canal. If a gouge is 
 used, cutting from without inward, it should be bevelled on its 
 convex surface, and should be applied very obliquely to the 
 surface of the skull, so that if the lateral sinus is exposed it will be 
 pushed ahead of the gouge and not wounded. Usually the inner 
 
634 SURGERY OF THE FACE, MOVTIl. AM) XECK 
 
 (vitreous) layer of the mastoid process, which separates the sinus from 
 the pneumatic cells, may be recognized when the latter have been 
 cleared away. If there is reason to suspect sinus thrombosis, this 
 bone must be removed also, and the sinus treated as recommended at 
 page 577. The facial ner\e is in most danger as it passes outward and 
 slightly backward beneath the floor of the (iditus ad antrum. The 
 horizontal semicircular canal projects into the median wall of the aditus 
 ad (iiitniDi. The curette should not be used in either of these situations. 
 The roof of the antrum and the aditus is very thin, and the middle 
 cratiial fossa lies directly above it; but this will not be opened if no lione 
 is removed above the line of the temporal ridge (continuation of the 
 posterior root of the zygoma). The condition of the bone forming 
 the tegmen antri should be ascertained by very gentle probing. If 
 it is carious or perforated it should be removed gently with curette 
 or gouge forceps, since there may be an extradural abscess above 
 it requiring drainage. The treatment of intracranial abscess has 
 been considered at page 581. 
 
 When the operation is concluded the cavity is lightly tamjjoned 
 with iodoform gauze, and the skin incision closed except at the lower 
 angle. An aseptic dressing is applied, and the head bandaged. The 
 after-treatment requires great care. The patient is confined to bed 
 for several days; and the wound is dressed on the third day. and the 
 gauze packing renewed. Not until firm granulations have formed 
 should syringing be employed, but the sinus left by the operation and 
 the external auditory meatus may be gently cleansed with pledgets 
 of absorbent cotton moistened with dilute hydrogen peroxide. The 
 subsequent care is that for any granulating surface. In the most 
 favorable cases healing is complete in from four to six weeks. 
 
 SURGERY OF THE LIPS AND PALATE. 
 
 Hare-lip and Cleft Palate. — These, which are conveniently con- 
 sidered together, are the most frequent congenital deformities of the 
 face. They are best understood by reference to the accompanying 
 diagram (Fig. ()74), which represents an embryo of three weeks. The 
 fronto-nasal process (a) is descending between the maxillary ])rocesses 
 (b h). The eyes are represented by c r. and the mandibular 
 processes by d d. Failure of the embryonal maxillary processes to 
 coalesce in the median line leaves a fissure of varying extent in the 
 upper lip and palate. 
 
 // the fissure is single, it does nqt occupy the median line but cor- 
 responds to the line of junction between the intermaxillary bone 
 (fronto-nasal process) and the superior maxilla. But a cleft of the soft 
 palate, antl one of the back part of the hard jialate is in the median 
 line, as the frontal process (intermaxillary bonej does not extend 
 backward so far. In a complete double cleft of the palate, therefore, 
 the fissure is Y-shaped, double in front, and single behind. 
 
Srix'af'Jh'y OF THE Lll'S AM) I'ALATE 
 
 035 
 
 //' fin- fi.s.snrc is double, the iiitennaxillary Ijoiic usually projofts in 
 front of the lip ( Fij;. (17")), and the fissures may inxoKc hotli |)alat(' and 
 lij). or citluT one to the exclusion of the other. As a f^eneral rule it may 
 he said that cleft i)alate without hare-lip is very rare, while hare-lip 
 without accompanying deformity of the palate is fairl\' conunon. 
 
 The projwr aijc for opcnifidii always has heen a matter of discussion. 
 As the existence of cleft i)alate is a more serious disability than that 
 
 of hare-lij), it should take |)recedence 
 in matter of operation. Where there 
 is no deformity of the palate, the best 
 time for ojxTation on the lip is from 
 six weeks to three months after birth. 
 Those surgeons who have most experi- 
 ence with these deformities have come 
 to share the opinion of Brophy, of 
 Chicago, who since 1900 has been urg- 
 ing that the best age for operation on 
 the palate is between the age of two 
 weeks and three months. When not 
 contraindicated, the hare-lip may be 
 repaired at the same time. But the 
 palate should be repaired before the 
 lip. Infants with cleft palate and hare-lip usually are stronger soon 
 after birth than subsequently, owing to the difficulty of suckling 
 them. In such young patients operation may be done without an 
 anesthetic if absolutely necessary; they have no apprehension of 
 pain or suffering to come, nor any memory of it after it has past. 
 
 Fi(i. r)74. — The hoatl of an cni- 
 hryo of three weeks. (See text.) 
 
 Fig. 675. — Double hare-lip and 
 cleft palate. Age two days. 
 Note the projecting intermaxil- 
 lary bone. Orthopaedic Hospital. 
 
 Fui. 676. — Hanging head position, for operations 
 on the palate. 
 
 But in most cases there is no contraindication to the use of ether or 
 chloroform. Ether is preferable in older children and in adults. It 
 is administered in the "hanging head" position (E. Rose, 1874), 
 and the surgeon stands at the patient's head, thus getting a good 
 view of the inverted palate (Fig. ()7()). The use of a mouth tube for 
 anesthetization is a great convenience. 
 
 Hare-lip. — Sitigle hare-lij) varies from a mere notch to a fissure 
 extendi;ig into the nostril, and perhaps continuous with a unilateral 
 
036 
 
 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 cleft of the palate. The principle of the operation consists in freshen- 
 ing the edges of the fissure and suturing them together. The lip is 
 
 Fig. 677 
 
 l"iG. 07S 
 
 Figs. 677 and 678. — Nelaton'.s method for iiifomplete single hare-lip. 
 
 first freely separated from the u])per jaw, by (li\iding the frenum or 
 other adhesions. Bleeding should be controlled promptly by mos- 
 
 FiG. 679 
 
 Fig. 680 
 
 Figs. 679 and 680. — Malgaignc's method for complete single hare-lip. 
 
 quito hemostats. If there is a mere notch in the lip it is sufficient 
 to employ Xelaton's operation (Figs. ()77 and ()7S) ; usually, however, 
 
 it is better to pare both edges of the 
 fissure in a line slightly concave toward 
 the median line. The knife is entered at 
 the apex of the fissure for denuding each 
 margin; and care is taken that these 
 incisions unite above the apex of the 
 fissure and that enough of each flap is 
 left at the free border of the lip to ensure 
 a projection on the vermilion border when 
 the edges are vmited (Figs. 079 and 080; 
 Malgaigne's operation, 1844) ; if the ver- 
 milion border is sutured flush, the con- 
 traction of the cicatrix soon will cause a 
 depression. Interrupted sutures of fine 
 silkworm gut or horsehair are used. They are introduced from the 
 cutaneous surface down to but not tlirough the mucous membrane. 
 
 Fig. 681. — Hare-lip pins in use 
 with twisted suture; points of pins 
 cut off and wrapped in adhesive 
 plaster. 
 
SUltGERY OF THE LJl'S AM) rALATE 
 
 y'uu 
 
 Or hare-lip pins and a twistrd suture may be used for the main sup- 
 j)()rt, with superlicial iuterrupli-d sutures to secure accurate coaj^tation 
 
 Fiti. (582 
 
 Fiu. 083 
 
 Figs. 082 and 083. — Owen's nietliod for coniijlete siiiKlc liarc-lip. 
 
 (Fig. (iSl). If the fissure is hirger than a mere notcli, it is better to 
 adopt some form of phistic operation, as indicated in I'igs. ()S2 and 
 
 Fig. 084 
 
 Fig. 68.5 
 
 Figs. 684 and 685. — Method of improving the shaj e of tlie iK-.stril. (Stone.) 
 
 (i83. To improve the nostril, a wire suture shotted at both ends may 
 be passed as indicated in Figs. 684 and 685. 
 
 Fig. 086 
 
 Fig. 687 
 
 Fig.s. 086 and 687. — Hagedorn's method for double hare-lip. 
 
 Double Hare-lip. — The operation here is the same as in cases of 
 single hare-lip, the margins of each fissure being freshened and sutured 
 separately; but often it is well to bring a small flap from the larger side 
 across beneath the intermaxillary bone, to form the prolabium; and 
 
08S 
 
 SURGERY OF THE FACE. MOrril, AXD XECK 
 
 if there is sufficient tissue a second still smaller flap from the other 
 side may be introduced between this flap anrl the intermaxillary bone 
 If the intermaxillary bone protrudes and cannot be pushed back intf) 
 place even by division of its attachment to the septum, it may be 
 excised; but as it bears the central incis(jr teeth this should not be 
 done recklessly. 
 
 After the operation the parts are painterl with Whitehead's varnish,' 
 and a long strip of adhesive plaster is applied from one ear to the other 
 across the upper lip. The baby should be put to the breast or fed 
 from a bottle as soon as convenient, as the motions involved in sucking 
 tend to lessen tension on the sutures. Minute doses of paregoric may 
 be reqiiirefl to check crying. Everv alternate stitch may be removed 
 about the fourth or si.xth day, and the remainder from the eighth to 
 the tenth day. 
 
 Cleft Palate. — If the operation is done in early infancy the max- 
 illar\" bone- are cartilaginous, and may be brought into apposition 
 by moderate pressure. This permits suture of the vivified margins 
 of the cleft without tension, and restoration of normal relaticms of 
 the parts concerned in phonation before the child begins to talk. 
 If the operation is not done until after the age of two years, and par- 
 ticularly in older children and adults, a much more flifhcult and terlious 
 method will have to be employed, and the patient will have acquired 
 improper habits of speaking which he never will be able completely 
 to abandon. When the operation for cleft palate is confined to the 
 -oh palate, it is known as fstaphyJorrhaphy: if it involves the hard 
 palate it is called uranoplasty. Before operatitjn is undertaken it is 
 important that the patient be free of coryza, pharyngitis, or other 
 inflammatory ronditions of the upper respiratory tract. 
 
 Early operation. — This consists essentially in passing sutures of 
 heavy wire across the cleft f^above the horizontal process f)f the palate 
 
 bone; from the buccal surface of one 
 maxilla to that of the other (Fig. (i88). 
 These sutures are then twisted tightly 
 together over perforated learl plates; and 
 when the maxill* are thus approximated 
 the margins of the palatal cleft (pre- 
 viously denuded) are sutured together 
 with interrupted sutures of silkworm gut. 
 The wire sutures are removed after four 
 to six weeks* Though some slight pres- 
 sure ulceration may occur beneath the 
 lead plates no permanent harm is 
 done. 
 Late Operation. —Here the maxilla cannot be approximated, and it 
 is necessary to close the cleft solely by means of the soft parts. The 
 
 ' Whitehead'.s varnish i.s made Vn- substituting for the spirit ordinarily u.sed in 
 the preparation of "Friar's Balsam" (compound tincture of benzoin;, a satu- 
 rated ethereal solution of iodoform, adding one volume in t«n of turpentine. 
 
 Fig. 688. — Wire sutures pas.sed, 
 for uranoplasty in infancj-. 
 
s(ii(;Kin' OF THE Lirs amj i'alaik 
 
 (•»;;<) 
 
 marjiins of tlic clct't arc tVeslu'iicd first; usually tlicy caiuiot he niacle 
 to meet e\cii under j^reat tension. Then an incision is made tliroufjh 
 the mucous membrane and periosteum of the hard palate close to the 
 alxcolar ])rocess; this is not carried so far posteriorly as to divide the 
 tnnik of the descendinu palatine artery as it emerges from the 
 posterior palatine foramen, 
 and it is placed so close to 
 the alveolus as to lea\c 
 most of the branches of 
 this artery on the median 
 side of the incision. Blccfl- 
 ing, which usually is very 
 free, is controlled by pack- 
 ing the incision with gauze 
 which is allowed to remain, 
 while a similar incision is 
 made in the palate of the 
 other side. The mucous 
 membrane and periosteum 
 are now separated from the 
 
 hard palate by suitable periosteal elevators from these lateral incisions 
 to the median cleft (Fig. ()S9). Even when these flai)s have been thus 
 freed, it may be impossible to make the edges of the cleft meet in the 
 median line without undue tension. The higher the arch of the palate 
 the easier will it be to make the flaps meet, when thus separated 
 fnmi the palate above. To overcome the remaining tension it may be 
 
 I'm. (3.S9. — Separating the luufo-jjeriostoal flap in 
 the operation for cloft palate. 
 
 I''iG. 090. — Cnttinji the aponeurosis (jf the 
 velum at its insertion in the hard palate. 
 
 Fig. 691. — Introduction of sutures, 
 in the operation for cleft palate. 
 
 necessary to divide the aponeurosis of the soft palate at its attachment 
 to the hard ])alate. This is accomplishetl by use of scissors bent on 
 the flat almost to a right angle; one blade is inserted l^etween the 
 detached mucoperiosteum and the under surface of the back of the 
 hard palate, and the other along the nasal surface of the soft palate 
 
640 
 
 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 (Fig. ()90). The freshened edges of the cleft are finally united hy inter- 
 rupted sutures of silkworm gut, passed by means of special mounted 
 needles, as indicated in P'ig. 691. The sutures may be secured by 
 clamping perforated shot over their ends. The wound is then 
 covered by Whitehead's paint. 
 
 In the after-treatment the patient, especially if an infant, must be 
 kept with the head low, and so placed that vomited matters, mucus, 
 blood, etc., find a ready exit. If no marked opposition is encountered 
 it is well to spray the mouth and nasal cavities with some Aveak anti- 
 septic solution e\ery three or four hours. Speaking should not be 
 permitted for a week at the least. Liquid diet, meat juices, or broth 
 being preferable to milk, should be employed until after removal of 
 the sutures, when soft diet may be allowed. The sutures should not be 
 removed for ten days unless they begin to cut out sooner. If the opera- 
 tion is not a success, from partial or complete sloughing, another 
 attempt should not be made for at least a month, so as to allow the 
 inflammatory swelling to subside. 
 
 Acquired Perforations of the Palate, the result of syphilis, of trauma, 
 or of sloughing following infection, are very difficult to close by opera- 
 tion, and none should be attempted imtil the parts are in healthy 
 condition. Usually a flap of mucous membrane must be inverted 
 from one or both sides of the perforation. These are sutured together 
 and the denuded area left to heal by granulation. In cases not admit- 
 ting of operative relief some form of obturator should be worn in the 
 form of a plate attached to the teeth. The obturator never should 
 be introduced into the perforation itself, as this would surely cause 
 it to grow larger by atrophy from pressure. 
 
 Macrocheilia. — Abnormal size of the lips, usually the lower, may 
 be due to a congenital condition of lymphangiectasis. This often 
 
 does not cause marked deformity until 
 the age of puberty. Or the condition 
 may be acquired as the result of hyper- 
 trophy following recurrent attacks of 
 cellulitis (Fig. 692). It frequently is ac- 
 companied by an adenomatous condition 
 of the mucous glands of the lip which 
 may be palpable as shot-like nodules 
 beneath the mucous membrane. The 
 treatment, if any is demanded, consists 
 in excision of a wedge-shaped section 
 all across the lip, with suture of the 
 mucous to the cutaneous border. 
 
 Cysts. — Cysts of the labial mucous 
 
 glands form small, rounded, submucous 
 
 tumors. They may follow biting the 
 
 lip. If punctured the cysts are apt to 
 
 refill, so it is better to excise the anterior wall and cauterize the 
 
 lining membrane. 
 
 Fig. 692. — Macrocheilia in a 
 boy of seven and a half years; 
 not congenital; followed cellu- 
 litis from injury at eighteen 
 months of age. Orthopaedic 
 Hospital. 
 
SURGERY OF THE LIl'S 04 1 
 
 Carbuncle. ('ail)Uiiclc', wIk-h it atlccts tlie upper lij), is lui unusu- 
 ally serious form of the disease, from the danger of intracranial com- 
 ])lications hy thrombosis and enii)olisni through the facial and angular 
 wins. Bullock recently has collected notes of 27 cases, witji six deatJis, 
 a mortality of 22 per cent. He advocates and practised with success 
 in one case, early ligation of the facial veins about half an incli l)elo\v 
 the inner canthus of each eye. Early and free incision of the car- 
 buncle is inii)ortant, regardless of aj)i)arent deformity, as this may be 
 remedied later by skin-grafting or i)lastic operation. 
 
 Epithelioma. — Epithelioma of the lip is a frequent condition, and 
 for successful treatment rccjuires early recognition. Ercfpientiy it 
 follows clironic local irritation, notably tlie heat from a short-stemmed 
 clay pipe; the explanation is that the moistened e])ithelium sticks to 
 the absorbent clay and is peeled off the lip as tJie pipe is removed. 
 An exfoliation residts, with a tendency to keratosis. Less than 9 per 
 cent, of cases of epithelioma of the lip occur in women; in men there 
 is only one case in the upper lip to 45 in the lower, while in women 
 there is one in the upper to every 7 in the lower lip (Butlin). The 
 lesion usually begins to one side of the median line on the vermilion 
 border of the lip (muco-cutaneous junction), and almost without 
 exception is of the more malignant deep-seated type of epithelioma. 
 An epithelioma begiiming on the cutaneous surface of the lip often is 
 of the less malignant superficial type (rodent ulcer). 
 
 The deep-seated epithelioma growing on the vermilion border of 
 the lip may arise in a seborrheic patch, or as a primary papilloma. 
 The former is much commoner. The lip is supplied by a row of seba- 
 ceous glands which often are visible in lips that appear to be normal, 
 " as a slightly shaded or as a glittering band that stretches like a bow 
 across the front of the lips between one corner of the mouth and the 
 other," about half a centimeter above the cutaneous border (Mont- 
 gomery). Somewhere on this line, crusts tend. to form, and a typical 
 seborrheic patch develops. Early invasion of the regional lymphatics 
 occurs; but they are microscopically infected long before they become 
 palpable. They should be searched for carefully, the finger of one 
 hand being placed in the floor of the mouth, and the fingers of the 
 other hand beneath the chin. The submental nodes are those first 
 affected, then those around the submaxillary salivary glands (both 
 sides), and finally the deep cervical lymph nodes along the great 
 vessels. The nodes at first are indurated, and usually painless; but 
 rarely are they distinctly palpable until the labial ulcer has existed 
 for many months. As already remarked, long before they are palpable, 
 probably within three or four months of the appearance of the lip 
 lesion, microscopical examination of the submental nodes will show 
 the presence of carcinoma cells. 
 
 As time goes on, the labial ulcer becomes a foul, fungating, stinking 
 
 crater; the cervical lymphatics form conspicuous tumors; they adhere 
 
 to the skin and form secondary ulcers of the same foul character as 
 
 in the lip. The patient cannot eat; the stench renders him loathsome 
 
 41 
 
042 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 to himself and every one near him; strenfjtli fjrachially fails; hemor- 
 rhaj?es from the growth may oecur; the trachea or esophagus may he 
 compressed; and he dies a miserable and painful death, hut not as 
 rapidly as he could wish. 
 
 Diagnosis. — The diagnosis seldom ofi'ers much difficulty. Epithe- 
 lioma occurs very rarely in ])atients under middle age; it is predis- 
 posed to by exposure to weather, by chrt)nic local irritation of any 
 kind; the area affected is covered with adherent crusts, which reveal 
 a small bleeding ulcer when remo\'ed; from the surface of the ulcer 
 it may be possible to squeeze out the epithelial i)earls and columns 
 of cancer cells lining the sebaceous ducts; the crusts soon form again; 
 and the regional lymph nodes are not palpably enlarged until the lesion 
 has existed for a number of months. A chancre of the lip is of much 
 more acute dcAelopment; may cccur at any age; is frequent on the 
 upper lip; presents parchment-like induration; does not tend to scab 
 but has a macerated or sloughy surface w^hich is very little inclined to 
 bleed; a history of contagion usually can be elicited; lymphatic enlarge- 
 ments occurs within a few weeks, the nodes being soft and juicy on 
 palpation; microscopic examination of smears from the lesion usually 
 will reveal the presence of the Treponema pallidum; in due time skin 
 lesions make their appearance; and antisyphilitic treatment is curative. 
 A (jumma of the lips is quite rare; it is painless; there is no lymphatic 
 enlargement; the history or evidence of other syphilitic lesions usually 
 can be obtained; and antisyphilitic* treatment is rapidly effective. 
 
 Prognosis. — The expectation of life in cases in which no operation 
 is done is from three to five years from the commencement of the 
 disease, and about eighteen months from the time of dift'use lymphatic 
 involvement. If radical operation is done before the lymphatics are 
 })erceptibly enlarged, from 50 to 60 per cent, of patients will be free 
 from recurrence three years later; of those in whom recurrence takes 
 place a small proportion can be permanently cured by a second opera- 
 tion, and the others will have an expectation of life dating from the 
 period of recurrence. Recurrence is much more apt to develop in the 
 lymphatics than in the lip; and a growth which develops in the lip may 
 not be a recurrence, strictly speaking, but a development of a new 
 epithelioma from a seborrheic patch in the neighboring skin used in 
 forming the new lip at the first operation. 
 
 Treatment. — A lesion on the lower lip which is merely suspected 
 of being carcinomatous should be excised, with a margin of at least 
 a quarter of an inch on all sides, and subjected to microscopical exami- 
 nation. If there is no evidence of malignancy this operation may be 
 regarded as sufficient. If the patient refuses to have the suspected 
 patch excised, treatment as for keratosis senilis (page 622) may be 
 instituted ; but the surgeon should not forget that he is dealing in the 
 lower lip with a very different form of epithelioma from the rodent 
 ulcer where such treatment is in a few cases successful. There need 
 be no anticipation of success if the growth on the lower lip is really 
 an epithelioma. If such a lesion is either clinically or microscopically 
 
.si.yi'(,7t7»'r OF rill': iJi'S 
 
 M'A 
 
 innlimKiiit, it is lunrssary to remove the udjacciit lymph nodes :ilso. 
 'I'lie growth on the lower lip should then he exeised with a mar^nn <)l' 
 at least a half inch on each sid'', hy incisions at ri,u;ht angles to the line 
 of the lip, not hy a \-shaped incision. 
 
 The ()peniti(.n introduced by (Jrant, of 1 )<'nver (1899), usually is 
 cnii)loyed now (Fi^^. ()9;> and (■)94). After excision of the lesion, usu- 
 all\ including- most of the lower lip, in form of a rectan^de, incisions are 
 carried downward and outward from the lower angles of this rectangle, 
 so as to expose the suhiuaxillary region on each side. These regions 
 are then cleared of lymi)h nodes, ligating the facial vessels if necessary. 
 Finally the submental l.\ ni])h nodes are removed through a separate 
 median incision. By drawing together in the median line the fiaps 
 outlined hy the two lateral incisions, the lower lip is well restored 
 without further i)lastic ])rocedure. The other chief merit claimed 
 
 Fig. 693. — Grant's operation for epithe- 
 lioma of the lower lip. 
 
 Fig. 694. — Grant's operation 
 completed. 
 
 for this operation is that it leaves the point of the chin untouched, 
 and that this serves as a firm basis of support for the new lower lip. 
 But it will be noted that this method of operation does not remove 
 the labial growth in one mass with its related lymphatics, but extir- 
 pates the diseased tissue in three or four separate sections. ^Moreover, 
 the cavity of the mouth is opened as the first step in the operation, 
 exposing the entire wound to contamination during the tedious dis- 
 section of the submaxillary and submental regions. 
 
 For these reasons I think it is l)etter to commence the operation 
 by the removal of the submental and su})maxillary lymphatics. These 
 regions are well exposed b\- making a long cur\'ed incision which cor- 
 responds to those incisions of Grant's operation which are represented 
 hv solid lines in Fig. 693. The skin over the point of the chin may be 
 left attached by carrying this first incision a little lower than indicated. 
 The flap thus outlined is (tissected dowaiward, including with the skin 
 
(544 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 only the platysma, and leavinj^ the fatty and lymphatic tissues m situ. 
 When the submental and both submaxillary regions have been exposed 
 in this way they are cleared of lymphatics and fat by dissection from 
 below upward; and the diseased structures are removed. Incisions 
 are then made upward into the mouth on each side of the labial 
 growth, and the lower lip is excised. The submental flap is then 
 sutured to the point of the chin, and the lateral flaps are united in the 
 median line as in Grant's operation. It is well to drain both sub- 
 maxillary regions from the outer angles of the lateral incisions for 
 several days. Where the dissection has been very extensive it is 
 better to carry a tube from the submental region in the median line 
 through the floor of the mouth, draining the buccal secretions directly 
 into the dressings, and thus lessening the chance of infecting the 
 suture lines. The portions of the skin incisions not drained should 
 be painted with Wliitehead's varnish (p. 638). 
 
 SURGERY OF THE TONGUE. 
 
 Tongue-tie. — It happens occasionally, though not so often as 
 mothers believe, that an infant is born with congenital shortness of 
 the frcBmim lingncB. The tongue then is held against the floor of the 
 mouth, cannot be protruded beyond the alveolar margin, and may 
 occasion slight difficulty in suckhng. The condition is easily remedied 
 by snipping with scissors the tense band close to the floor of the 
 mouth (to avoid the ranine vessels which run beneath the tongue), 
 and then stripping the tongue upward by the fingers as far as needed. 
 The bifid blade at one extremity of the grooved director (Fig. 700) is 
 a convenient retractor to hold the tongue away from the floor of the 
 mouth, while the frenum is being divided. If the separation of the 
 tongue from the floor of the mouth is carried too far, there is danger 
 of the baby being suft'ocated by "swallowing" the tongue. 
 
 Macroglossia. — Abnormal enlargement of the tongue, when not 
 dependent upon constitutional causes, such as cretinism, may be 
 congenital or acquired, as in the pathologically analogous condition 
 of macrocheilia (p. 640), and from similar causes. In congenital 
 cases the patients usually are mentally deficient. The protruding 
 tongue becomes inflamed and dry from exposure to the air, resulting 
 in stomatitis, with collection of sordes, fetor of the breath, etc. In 
 time the incisor teeth of both jaws are pressed forward and the alveolar 
 processes are distorted ; but this deformity rarely becomes permanent 
 before the tenth year. 
 
 Treatment. — Treatment consists in partial excision, usually of a 
 wedged-shaped portion of the tip of the tongue, with suture of the 
 remaining lateral flaps in the mid-line. Or, as the thickness of the 
 tongue usually is more obnoxious than its breadth, a transverse resec- 
 tion may be done, making superior and inferior flaps. Preliminary 
 ligation of the lingual arteries may be advisable if the tongue is very 
 large, and Armstrong recommends the use of silver wire instead of 
 
HVIiCEUY OF THE TONGUE 
 
 045 
 
 silkworm mit for suturing the tonjiuo. The best time for operation 
 is from the third to the sixtii year. 
 
 Ranula. UaiuiUi is a eystie tumor between the tonj^ue and the floor 
 of the moutii. It is a ehnieal term, possibly deseriptive of the frog- 
 like appearance of patients when the growth is very large. Though 
 occasionally congenital, in the vast majority of cases it is acquired; 
 usually it is considered a retention cyst of one of the sublingual glands 
 or its duct. It is not improbable that its pathogenesis is similar to 
 that of galaetocele (p. 703). Occasionally a salivary calculus may 
 be the cause of obstruction of the duct, but as a rule no cause can be 
 found. The cyst in most cases is of slow development and chronic in 
 (hiration. It is unilocular. Conditions described as acute, and as inter- 
 mittent ranula are also recognized, though very rare. In the acute 
 cases a swelling suddenly a])pears beneath the tongue, the mucous 
 membrane lining the floor of the mouth is raised above the dental 
 border, salivation is profuse, 
 speech, deglutition, and even 
 respiration are interfered with, 
 and suffocation may threaten. 
 Astringent washes usually are 
 sujQficient to relieve the symp- 
 toms, and the cystic swelling 
 may disappear as rapidly as it 
 came, as w^as the case in the 
 only patient with this rare af- 
 fection I have seen; but some- 
 times incision is required. In 
 the chronic cases the cyst, 
 though unilateral at first, may 
 spread so as to involve the 
 entire sublingual region; very 
 seldom at the present day is 
 it allowed to grow so large as to project in the submental region. 
 The mucous membrane slides freely over it, and its surface often is 
 covered with dilated and tortuous veins (Fig. 695) ; it is semi-trans- 
 lucent, and the contents are a viscid, ropy, mucus. Ranula is most 
 likely to be confounded with dermoid cysts, which, however, are rare; 
 a dermoid cyst has thicker walls, pits on pressure, and is not trans- 
 lucent. 
 
 Treatment. — Excision of the anterior wall of the cyst, and scraping 
 or cauterizing the remaining portion of the lining membrane, and 
 packing the cavity with gauze until healing by granulation takes 
 place, usually effect a cure. But unless a thorough operation is done 
 and the after-treatment efficiently conducted, recurrence will take 
 place. The operation can be done under cocain anesthesia, through 
 the mouth. 
 
 Ludwig's Angina, or Angina Ludovici, is a condition first accurately 
 described by Ludwig in 1834. It is an acute septic inflammatory 
 
 Fig. 695. — Ranula. Age eleven years; 
 duration over one year. Projecting cyst is 
 dark blue from overlj-ing vein. Episcopal 
 Hospital. 
 
()4() SURGERY OF THE FACE, MOUTH, AND NECK 
 
 process involving the cellular tissues of the floor of the mouth and the 
 submaxillar!/ region of one or both sides of the neck. It is imjjortant to 
 note that in this definition the main chnical features of the disease are 
 indicated. It affects the coiniective tissue spaces, being a ceUuhtis, 
 as asserted by G. G. Davis (190G), not a lymphangitis; the lymph 
 nodes and the submaxillary and sublingual salivary glands are not 
 primarily diseased, but may be invaded secondarily. It involves both 
 the floor of the mouth and the cervical tissues. It is not confined to 
 either. Usually it owes its origin to infection from dental lesions, 
 and often commences after the extraction of teeth; but it may begin 
 in the tonsil or other intrabuccal structure. The cellulitis spreads 
 with great rapidity from the floor of the mouth around the posterior 
 border of the mylo-hyoifl muscle, a route to which attention was 
 called by T. T. Thomas in 1907. Both sides of the neck are affected. 
 The submaxillary gland and lymph nodes usually are found more or 
 less intact in the centre of a necrotic area of cellular tissue. 
 
 It is not unusual for groups of patients to be affected nearly simul- 
 taneously, but the disease does not seem to be contagious. 
 
 Symptoms. — The onset of the disease is marked usually by difficulty 
 in talking and swallowing, pain in the floor of the mouth, salivation, 
 and finally dyspnea. The patient becomes profoundly septic, but 
 gives evidences of little or no constitutional reaction. The temjiera- 
 ture often is not very high, nor is there marked leukocytosis. Edema 
 of the glottis may occur at any time, and T. T. Thomas believes this 
 is the usual cause of death; but in many cases death seems to be due 
 to toxemia, and suft'ocati^'e symptoms are entirely absent. 
 
 Diagnosis. — The diagnosis depends on recognizing a possible cause; 
 on demonstrating a cellulitis both in the floor of the mouth and in the 
 upper cervical regions, perhaps extending to the clavicle, and often 
 more marked on one side; and on the rapid progress of the disease 
 to a fatal termination unless relieved by efficient treatment. 
 
 Treatment. — As soon as the diagnosis is made, and without waiting 
 for the development of more serious symptoms, the parts should be 
 incised. This may be done under local anesthesia; general anesthesia 
 may be out of the question, owing to the sufl'ocative symjitoms. An 
 incision is made directly in the median line in the submental region, 
 between the genio-hyoid muscles; the knife is pushed up into the floor 
 of the mouth, emerging just behind the symphysis menti. There are 
 no structures of importance in the median line. A drainage tube is 
 then drawn through from the submental region to the floor of the mouth. 
 An incision is then made in one or both submaxillary regions, and a 
 tract is made by thrusting a hemostat into the mouth through the 
 mylohyoid muscle. Tubes are then inserted in these additional tracts; 
 or one long tube may be made to pass from one submaxillary region 
 to the other across the floor of the mouth a})ove the mylohyoid muscle 
 (Fig. 696). In addition, if the sublingual tissue is markedly edematous, 
 it is well to incise the mucous membrane of the floor of the mouth 
 from the mid-line to the second molar tooth, as advised bv J. W. 
 
Sl'h'dl'Hn' OF THE TOXdl'K 
 
 (;i7 
 
 Fig. 696. — Ludwig's angina, in a 
 patient of twenty-two years. After 
 operation. (Dr. J. W. Price, Jr.'s 
 ca.se.) Episcopal Hospital. 
 
 Price (190S), and <i;('iitly to curette wluTcNcr a soft spot is t'ouiid. 
 
 I'sually little or no pus is found, the infection heinj:; so severe that the 
 
 tissues are unahle to react. The i)arts are dressed with hot, moist 
 
 antiseptic i;au/e, to form a j)oultice. 
 
 Concentrated mitriment and stinni- 
 
 hmts should l)e jii\-en. Traclieotomy 
 
 is recpiircd when edema of the <;Iottis 
 
 occurs. The mortahty of theafi'ection 
 
 has varied from 20 to 40 ])er cent., 
 
 in different series of ea.ses. 
 
 Glossitis. Acute Superficial Glossi- 
 tis may foUow hums, scahls, or other 
 injuries, and the lesion may be 
 catarrhal in character, or associated 
 with destruction of the mucous mem- 
 brane and the formation of one or 
 more ulcers. Stomatitis of similar 
 form may coexist. Healing readily 
 occurs, as a rule, under the influence 
 of alkaline mouth washes. An indo- 
 lent ulcer may be touched with a 
 drop of pure carbolic acid. 
 
 Acute Parenchymatous Glossitis, in 
 which the tongue suddenly becomes 
 immensely swollen, threatening suft'ocation, is described by system- 
 atic writers. It is an infectious process, analogous to but rarer than 
 Lud wig's angina, and not aft'ecting the sublingual nor the cervical 
 tissues. Treatment consists in incising the dorsum of the tongue 
 to the depth of 5 to 10 mm., each side of the median raphe, for a dis- 
 tance of about two inches. This rapidly relieves the .swelling. 
 
 Abscess of the Tongue may be acute or chronic. P'ither form is rare, 
 and the chronic form may be indistinguishable from a dee]) gumma 
 of the tongue. If fair trial of antisyphilitic treatment causes no 
 improvement, an exploratory incision should be made. Incision is 
 the proper treatment also for acute abscess. 
 
 Chronic Superficial Glossitis is known by various other names, more 
 or less descriptive of different stages of the disease. The best known 
 and most used is Leukoplakia. Other names are Leukoma, Leuko- 
 keratosis, Smokers' Patches, Psoriasis, and Ichthyosis of the Tongue. 
 These conditions derive their surgical importance from the fact that 
 they are recognized as precancerous diseases, analogous to the senile 
 keratosis of the skin discussed at page ()22. The pathological change 
 in the tongue consists in a proliferation of the epithelial cells, col- 
 lection of leukocytes, and scar formation immediately beneath the 
 epithelial layer. The patches may occur on the tongue alone, on the 
 cheeks and lips alone, or on both tongue and other buccal surfaces. 
 They are seen oftenest on the dorsum of the tongue near its tip, but 
 not in the median line. Thev never occur behind the circumvallate 
 
CAS SURGERY OF THE FACE, }fOUTH, AND NECK 
 
 papillse. They may be small or large, irregular, circular, circinate, or 
 "geographical" in outline; they always spread, and different patches 
 frequently coalesce. Early in the disease the patches appear as red, 
 shiny, smooth areas on the tongue, surrounded by a distinctly furred 
 area of mucous membrane (Smokers' Patches). Later these patches 
 become bluish white, but retain their characteristic smoothness 
 (Leukoplakia). Still later some evidences of thickening and indura- 
 tion are present, the patches are furrowed, and the fissures may be 
 ulcerated (Leukokeratosis). This stage borders on the development 
 of carcinomatous changes. 
 
 Cause. — The cause of this affection is not known, but is definitely 
 related to several forms of chronic irritation. Of these the most impor- 
 tant is smoking or the use of tobacco in any form; probably it is the 
 chemicals in the tobacco, combined with the mechanical irritation, 
 and, in the case of smoke, the heat, that renders its use so harmful. 
 But many cases occur in those who have never used tobacco. Other 
 predisposing causes are syphilis, when its tertiary stage is reached; 
 psoriasis, or ichthyosis, elsewhere in the body; the presence of 
 broken, or decayed teeth; irritation from badly fitting vulcanite 
 dental plates, etc. 
 
 Symptoms. — The earliest symptom, which may be overlooked for 
 many months, is smarting in the tongue after excessive smoking or 
 drinking; later, pain is felt whenever highly seasoned or hot food is 
 taken. But the patient may discover the patches accidentally, on 
 looking in the mirror; or they may be called to his attention by his 
 dentist or physician before any definite symptoms have arisen. 
 
 Treatment. — The use of tobacco in any form should be absolutely 
 prohibited until entire disappearance of the lesions. Any other form 
 of irritation, whether due to dental conditions or dietary indiscretions, 
 should be remedied, and unirritating, preferably alkaline, mouth 
 washes should be ordered. Cauterization of the lesions usually makes 
 them worse. If there is a single, small, localized lesion, it may be 
 excised. If epithelioma is suspected, a portion of the patch should 
 be excised for microscopical examination. 
 
 Tuberculosis. — Tuberculosis of the tongue is rare. The lesion 
 commences as a tuberculoma, but very seldom is it seen until this has 
 broken down, leaving an ulcer. Usually the lesion is secondary to 
 tuberculous disease elsewhere (lungs or larynx), and this gives the 
 clue to the diagnosis. The tuberculous ulcer appears at the tip or 
 edges of the tongue, rarely on the dorsum; it is superficial and lies in 
 the long axis of the tongue; it is not indurated; has not raised or 
 thickened borders; secretes thick and yellowish pus; and may be 
 surrounded by caseous foci. It is commonest in men and in adults 
 (Plate IV, Fig. 1). The ulcer is very painful. Early invasion of the 
 cervical lymph nodes is usual. 
 
 Treatment. — In the very rare cases where tuberculosis is primary 
 in the tongue it is proper to excise the lesion together with the enlarged 
 lymph nodes. In most cases, however, nothing can be done save to 
 
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SURGERY OF THE TONGUE G40 
 
 relieve the pain l)y loeal use of cocain or other anesthetic. Armstrong 
 says si)rayin^- the all'ected area with ;i 1 per cent, solution of carh(jlic 
 acid, to which a Httle sodium hi( arhonate has heen added, sometimes 
 is soothing. 
 
 Syphilis.- -Syphilis of the tongue is of most surgical interest in the 
 gununatous stage. Chaiicrr and )iincou6- paiclici of the tongue and 
 mouth present the same characteristics as these lesions elsewhere, 
 and their diagnosis seldom is difficult. Gumma of the tongue may be 
 single or multiple, superficial or deep. The lesions occur chiefly on 
 the dorsum of the organ; they soon break down, and are a])t to coalesce, 
 forming large irregular, nearly painless ulcers with overhanging edges 
 and covered with an adherent slough. The ulcers do not tend to 
 bleed when the slough is pulled away; they are not indurated; they are 
 not accompanied or followed by enlargement of the cervical lymph 
 nodes; a history of i)revious syphilitic lesions usually can be obtained; 
 and they rapidly improve under the administration of the iodides. 
 These features serve to distinguish them from carcinomatous ulcers 
 (p. 650). Diffuse gummatous glossitis as it heals leaves a charac- 
 teristically fissured and furrowed tongue (Plate IV, Fig. 2). 
 
 Sarcoma.— Sarcoma of the tongue is very rare. Serafini, in 1910, 
 reported what he believed w^as only the thirty-second case on record. 
 
 Carcinoma. — In the tongue this occurs almost invariably in the 
 form of ei)itlielioma, though a few cylindrical-celled carcinomas have 
 been recorded. It is much more common in men than in women 
 (about 15 to 1), and quite unusual before middle life. Frequently it 
 seems to be brought on by chronic irritation, such as that from a 
 broken tooth, from tobacco smoke, or the stem of a pipe (Plate IV, 
 Fig. 3). The pre-cancerous lesions of the tongue already have been 
 discussed (p. 647), and Butlin demonstrated not long ago that many 
 lesions, previously considered by him and others as pre-cancerous, 
 prove on microscopical examination to be actually malignant. 
 
 Usually the epithelioma begins in a fissure, an ulcer, or a patch of 
 leukoplakia. Sometimes, but rarel}', it appears first as a wart or 
 papilloma; and any such growth on the tongue which does not disap- 
 pear very promptly after removal of a recognized source of irritation 
 should be considered malignant. The epithelioma commonly appears 
 on the lateral margin of the tongue, very rarely at the tip, and almost 
 never on the dorsum. It begins occasionally as a submucous growth, 
 but even in such cases it is very seldom seen until an ulcer has formed ; 
 and in the vast majority of instances it develops in a preexisting 
 erosion or ulcer. It may begin in the floor of the mouth, but it is 
 more usual for this to be invaded secondarily. A cancer in the ante- 
 rior third of the tongue tends to spread to the floor of the mouth and 
 mucous membrane covering the alveolus; it early invades the sub- 
 mental and submaxillary lymph nodes, first those on the same side as 
 the grow^th, but later the involvement is bilateral. Next the deep 
 cervical chain is invaded. The submaxillary and sublingual salivary 
 glands usually are not invaded. A cancer in the yosterior two-thirds 
 
650 
 
 SURGERY OF THE FACE, MOI'TH, AXD NECK 
 
 of the tongue tends to spread to the soft palate and pharynx; it invades 
 the lymphatics of both sides very early; first the submaxillary, then 
 the deep cervical. When the latter have been invaderl by cancer 
 arising in any part of the tongue, the growth spreads up their chain 
 to the base of the skull and downward to the clavicle. Distant 
 metastases occur very late and are quite unusual. In the vast 
 majority of cases the disease is distinctly limited to the face and neck. 
 When once the cervical lymph nodes are invaded, the tumor may 
 grow in them with alarming rapidity, and these secondary growths 
 may quite over-shadow the original trouble. The same progressively 
 fatal course, but even more rapidly, is observed here as in the cervical 
 growtlis following carcinoma of the lip (p. 641). 
 
 Symptoms. — Pain and smarting in the diseased area, especially 
 on smoking, drinking alcoholic beverages, or eating hot or highly 
 
 seasoned food, usually are the 
 first things to attract the patient's 
 attention. The tongue, or the 
 whole mouth, may feel sore. 
 There is difhculty and pain in 
 swallowing, and the patient 
 refrains from eating. Later 
 even liquids can scarcely be 
 taken. The tongue feels thick 
 and clumsy. Speech becomes in- 
 distinct. Salivation is increased. 
 Pain may be referred to the ear 
 if the growth is far back in the 
 tongue. Very rarely is pain al- 
 together absent ; but occasionally 
 the patient is unaware of his 
 condition until the tumor is . 
 inoperable. From inability to 
 eat, sleepless nights, and constant pain, the patient rapidly becomes 
 emaciated. If secondary infection occurs, there will be added fever- 
 ishness, chilliness, and increased secretion from the tumor, with hor- 
 rible fetor of the breath. Hemorrhages may occur from the mouth 
 or from secondary ulcers in the neck. Death may occur from such a 
 complication or from septic inhalation pneumonia, but more often 
 follows a short period of delirium due to toxic absorption. 
 
 Diagnosis. — Carcinoma of the tongue must be distinguished chiefly 
 from tuberculous and syphilitic ulcerations. The characteristics of 
 these have been considered already (p. 648); but it should not be 
 forgotten that carcinoma frequently develops in a syphilitic lesion. 
 In carcinoma the main diagnostic points are the hardness of the 
 ulcer's base; the thickness f)f its margins, the bleeding when the adher- 
 ent slough is removed, exposing an uneven floor; the patient's age; 
 and the existence of some chronic form of local irritation. Any ulcer 
 even suspected of being carcinomatous should l)e subjected to micro- 
 
 FiG. 697. — Recurrent carcinoma of floor 
 of mouth. Excision of tongue by intra- 
 buccal method in September, 1909, three 
 months after appearance of growth. Re- 
 currence in Xoveml)er. 1909. Photograph 
 February 14, 1910. ^E>r. H. C. Deaver's 
 case.) Episcopal Hospital. 
 
s[R(;KRy or the roxacE i\n\ 
 
 scopical study. A portion ol' tlu' ulcer may ])v rcniowd easily hy 
 pullin<i tlie touffue far out of the nioutli and injeetinj; a few euhic centi- 
 meters of eucain solution ((> j)er cent.) beneath the ulcer; a portion 
 of the indurated margin of the nicer is then pinched up in forceps and 
 cut oH' with scissors. I^nlarj^enient of tlie lympli nodes never should 
 be depended u|)on for a clinical diagnosis. Lonjj before they are palpa- 
 ble they arc nncrosc()])icall\' diseased, ^'et the presence of enlarj,a'd 
 lymph nodes points to carcinoma rather than to <i tertiary syphilitic 
 lesion. 
 
 Prognosis. In cases entirely untreated, the expectation of life is 
 not more than eijjhteen months from the time the growth is recog- 
 nized. In many cases death occurs in less than nine months. By 
 radical surgical treatment the expectation of life is almost doubled, 
 and a certain luimber of patients (25 per cent, in Butlin's statistics), 
 in whom early oj)eration is tlone, remain free of recurrence for many 
 years or until death from some other malady. Even in cases where 
 recurrence takes place, this is almost always in the neck, and the 
 patient is still able to take nourishment and does not suffer nearly so 
 much ])ain as if the tumor was still growing in the mouth. The imme- 
 diate mortality after radical operation is in general from 15 to 20 per 
 cent. It is lower in uncomplicated eases, and much higher when part 
 of the mandible or pharynx has to be removed. 
 
 Treatment.- — Owen well says that most of these patients come to the 
 surgeon when the tumor is so far advanced, that if he considered only 
 his own peace of mind he would decline to undertake any operation. 
 But whenever it is not inoperable, radical removal of the growth and 
 the ralated lymph nodes is the only rational treatment. In deciding 
 for or against operability, the surgeon should examine especially the 
 local extent of the disease, and the range of lymphatic involvement. 
 A caiK^er of the tongue cannot be considered inoperable merely because 
 it has invaded the floor of the mouth or has eaten into the mandible. 
 But if the entire floor of the mouth, on both sides, is densely infiltrated, 
 and especially if the growth has extended along the anterior pillar 
 of the fauces to the soft palate or pharynx, it generally will be impos- 
 sible to cut wide enough of the growth to ensure freedom from local 
 recurrence. In regard to lymphatic involvement, the surgeon should 
 examine carefully and repeatedly the deep cervical lymphatics extend- 
 ing u]) to the l)ase of the skull. If these are manifestly involved, and 
 certainly if they are immovably adherent to the spinal muscles or the 
 skull itself, he should decline to interfere with them. Involvement 
 of the lymphatics downward is not so serious a matter, since it is 
 very seldom that the disease process passes beyond the subclavian 
 triangle; and the contents of this triangle and those above it can be 
 removed with comparative facility by modern methods. 
 
 ]\Iost surgeons prefer to do in two stages whatever form of operation 
 is undertaken. Armstrong, however, removes both the lymph nodes 
 and the tongue at the same sitting. Usually the lingual growth is 
 removed first; and after a week or ten days the cervical lymphatics 
 
052 SFRGERY OF THE FACE, MOJ'TH, AXfJ XECK 
 
 are dissected out. In early cases (3 to o months' duration) it may be 
 sufficient to remove the lymphatics only from the bifurcation of the 
 carotid up to the tongue and base of the skull; in more advanced 
 cases the dissection must commence as low as the clavicle. If only 
 the anterior third of the tongue is involved, most surgeons consider 
 it sufficient to remove the submental nodes and the cervical nodes of 
 the same side as the lingual lesion; but Da Costa urges that even in 
 such cases the cervical lymphatics also on the other side should be 
 excised, as he has found them involved at a very early stage. Nearly 
 all authorities are agreed that, when the tumor involves the posterior 
 part of the tongue, the lymphatics from both sides of the neck ought 
 to be removed. This may require the division of the operation into 
 three stages. Owen recommends, if the lymph nodes are increasing 
 very rapidly in size, that the first operation should consist in extirpat- 
 ing them, since if the tongue is removed first, and the operation on 
 the Ijinph nodes postponed for a couple of weeks, they may have 
 become inoperable by that time. 
 
 The questions of the preparation of the patient and of the anesthetic 
 are of importance. For several days previously special attention 
 should be given to cleansing the patient's mouth,' and improving so 
 far as possible, his general health. Xo operation should be done while 
 there is an acute bronchial or pulmonary lesion. The anesthetic, 
 preferably ether, should be given by a skilled anesthetist; wherever 
 possible (and this should be the case in every well appointed hospital) 
 the method of intratracheal insufflation (p. 154j should be employed. 
 This minimizes or altogether prevents the chance of pulmonary com- 
 plications, and permits the operation to be done in the head-high 
 position, which markedly decreases the quantity of blood lost. If 
 this method cannot be used, one of the other methods recommended 
 at p. 153 for operations on the head and neck should be employed. 
 A h\"podermic of morphin and atropin should be given shortly before 
 beginning the operation. 
 
 The cervical lymphatics are well exposed by the incisions recom- 
 mended by Butlin (Fig. 698). The two triangles outlined are dissected 
 free, the flaps being composed of skin alone, especially in the submental 
 and submaxillary regions. If necessary another incision may be carried 
 out^^'ard along the clavicle. All the fat and lymphatic tissues are then 
 cleared out in one mass, beginning at the cla^'icle and working upward 
 along the great vessels and forv^-ard to the region of the jaw. The 
 common carotid artery may be temporarily clamped, close to the 
 subclavian. The sternomastoid muscle may be divided or excised 
 with the deeper structures to facilitate the dissection. The internal 
 
 II have used Talbot's iodo-glycerole mouth wash with good efifect before and 
 after operation: 
 
 ^ — Zinci iodidi Cpur.), 3 parts 
 Water, 2 " 
 
 lodin cr\'stal.«, 5 " 
 
 Gljcerin, 10 " 
 
SURGERY OF TllK TONdUE 
 
 ()5:i 
 
 juuiilar vein may be excised if the ^aowth is densely udiiereiit; and the 
 va^us nerve, and even the eoniinon earotid artery may be extirpated 
 if neeessarv.' lUit in tiiose i)ast fifty years of aj^e removal of the (-arotid 
 is inadvisable on aeeount of the danger of softening of the bram and 
 paralysis (Crile). 
 
 Yio. 698.— Butlin's incisions for extirpation of the corvical lymphatics. 
 
 For partial or complete removal of the tongue, various methods are 
 
 in use. ^, 
 
 Intrabuccal Method {Whitehead's Operatioji, 1881).— The tongue is 
 held within the mouth chiefly by the frenum and the anterior pillars 
 of the fauces. If these, and the mucous membrane between the 
 tongue and the mandible, are divided, the tongue can be pulled far 
 out of the mouth (Roux, 1839). In growths involving only a small 
 area on the anterior part, it usually is sufficient to remove the half 
 of the tongue diseased. A stout linen ligature is passed through the 
 tip of the tongue on the healthy side, and after dividing the frenum 
 and the mucous membrane on the diseased side of the floor of the 
 mouth, the tongue is split down the middle by scissors, and the half 
 to be removed is cut squarely across at least three-quarters of an inch 
 behind the growth. The arteries are caught as they are cut : the lingual 
 in the floor of the mouth, and the dorsalis linguae as it spurts from the 
 stump. The^' are tied securely, and the mucosa of the remaining half 
 of the tongue is sutured to the border left attached to the mandible 
 of the diseased side. If the entire tongue is to be removed by this 
 method, each half of the tongue is removed separately, as above 
 described, the precaution being taken to secure the stump of the 
 tongue (glosso-epiglottidean fold) by a strong linen ligature before the 
 second half is removed. This ligature is useful in controlling hemor- 
 rhage, and should be left hanging out of the mouth for a few days, 
 to aid in overcoming any respiratory difficulty. 
 
 Method hi/ Division of the Symphysis Menti.— This operation was 
 introduced by Sedillot (1844), and a few years later by Syme. Kocher 
 
()54 SiRdEHY OF THE FACE, MOLTII, AND NECK 
 
 has recently adopted it as his normal method. It is used for removal 
 of the entire tongue in cases where the floor of the mouth is involved. 
 The lower lip is divided in the mid-line, and this incision is carried 
 down to the hyoid bone. The mandible is then drilled in two places 
 on each side of the mid-line, to facilitate its subsequent wiring. The 
 symphysis is then sawed through, and the halves of the mandible 
 are separated. Rough handling may cause a fracture. The mucous 
 membrane on the floor of the mouth is then divided, the lingual arteries 
 are caught and tied, and the tongue, with as much of the floor of the 
 mouth as necessary, is removed in one mass. The stump, with the 
 two spurting dorsales lingua^ arteries, is treated as in Whitehead's 
 method, over which this operation presents few advantages. The 
 exposure is not wvy much better, the wound left is very prone to 
 infection, and the jaw frequently fails to unite solidly. 
 
 Suhnia.villari/ Method.'^. — Regnoli (1S3S) exposed the tongue by a 
 transverse suprahyoid incision, for removal of its anterior portion. 
 For a growth confined to the base of the tongue, Kocher has adopted 
 subhyoid pharyngotomy. For tumors at the side of the tongue invading 
 the floor of the mouth, Kocher formerly employed an incision from the 
 symphysis downward, then backward, and finally upward to the 
 mastoid; this is still known as Kocher' s method. The skin-flap thus 
 outlined is turned upward, the lymphatic tissue in the upper part 
 of the neck is removed, and the external carotid artery and facial 
 vein are ligated if necessary. The submaxillary salivary gland is 
 removed, because though seldom itself invaded, there usually are 
 lymph nodes imbedded in its lobules. The mouth is opened at the 
 posterior border of the mylohyoid muscle, and the attachments of 
 the tongue to the hyoid bone are severed. Then the tongue is drawn 
 down into the wound, and its base is cut across. The wound must 
 be freely drained, by a large tube passing from the buccal cavity out 
 at the incision in the neck. Langenbeck\s Method (1875) consists in 
 making an incision from the angle of the mouth downward to the 
 level of the thyroid cartilage, with division of the mandible between 
 the first and second molar teeth, thus approaching the tongue from 
 the side. 
 
 When it is necessary to excise a portion of the tiinndible along with 
 the tongue and the floor of the mouth, Oespiand Bastianelli's modifi- 
 cation (1S90) of Langenbeck's method is to be preferred. The lower 
 lip is divided in the median line, and the incision is carried backward 
 to the mastoid, well below the jaw, as in Kocher's method. After 
 clearing the upper cervical region, and ligating the external carotid 
 artery and the facial vein, the mandible is divided well in front and 
 behind the growth, and the tongue and floor of the mouth are removed 
 in one piece with it. A similar operation gives the best exposure for 
 cancer arising in or involving secondarily the floor of the mouth, 
 whether or not excision of the mandible is required. To remedy 
 the defect in the floor of the mouth, the remaining half of the tongue 
 (if it has not required removal) may be split parallel with the floor of 
 
OI'I'Jh'ATlOXS ().\ TlIK MR SINUSES <)')5 
 
 tlif iiioutli, and thus cuii l)c sj)R'a(l out lar rnou^li to \)v sutured to 
 the mucous nienihrane of the cheek, above the alveolus (v, Eiselsberg, 
 1«)()4; W. Bartlctt. I!)()7). If the niaudihle is not already edentulous 
 the teeti) may he pnllcil, and any unicous memhrane still adherent 
 to the jaw may he dissected away. 
 
 After removal of the tongue the patient still can make himself 
 understood, and swallowinji; is not interfered with. 
 
 Pallidflrc Oprration.s sometimes are possible, even when the disea.se 
 is too far advanced to ati'ord hoj)e of cure. The most important of 
 these methods is extirpation of the external carotid arteries, on l)oth 
 sides, as introduced by Dawbarn (lOO.'i), to effect starvation of the 
 lingual growth. Or they may be injected with paraffin. These 
 methods are not aj)plical)le to cases where the lymphatic in\'olve- 
 ment over-shadows the original growth. The use of radium emana- 
 tion and of the .c-ray may be valuable in allaying pain, and in 
 diminishing fetor and secretion. 
 
 OPERATIONS ON THE AIR SINUSES. 
 
 The air sinuses are mucous-lined cavities draining into the nasal 
 passages, and like the middle ear are prone to become infected when 
 their drainage is obstructed. The cure of adenoids, deflected septum, 
 hyi)ertrophied turbinates, and other seemingly mimjr conditions, 
 therefore, becomes important as a prophylactic against more serious 
 ailments. Acute infections of these accessory sinuses usually are 
 treated successfully by the rhinologist by the intranasal route, and -are 
 by no means so important surgically as chronic infections, which 
 require radical operation for their relief. These chronic lesions may 
 consist merely of empyema of the sinus affected, or there ma\' be 
 exuberant (jranidation tissue, or even mucous polypi. As all these 
 afi'ections are rightly considered a part of the specialty of nose and 
 throat disea.ses, it seems inexpedient to do more here than outline in 
 the briefest possible manner the nature of the operations at present 
 employed in their treatment. An acute exacerbation of a chronic 
 lesion may occur at any time, and may be quickly fatal, especially in 
 the case of the frontal, ethmoidal, and sphenoidal sinuses, unless 
 immediate adequate drainage is provided. 
 
 The diagnosis of chronic sinusitis is not always easy, l)ut depends 
 in large measure upon persistent discharge of pus, found by intranasal 
 examination to enter the nasal passages in the region where the 
 suspected sinus normally drains. There are in addition, when drain- 
 age is inefficient, usually headache and localized tenderness. In 
 ethmoidal disease the pain usually is referred to the bridge of the nose 
 and the eyeball; in sphenoidal sinusitis it usually is between the eyes 
 and in the occipital region; in frontal sinusitis the pain and tenderness 
 are localized to the region above the root of the nose and the inner 
 margin of the orbital cavity, and occasionally the pus perforates 
 anteriorly and forms an abscess at the root of the nose; in maxillary 
 
05G SURGERY OF THE FACE, MOUTH, AND NECK 
 
 siunsUis the i)ain may l)e referred to the teeth, the nose, or all over 
 the head, but tenderness usually is localized to the maxillary bone. 
 As a preliminary to all these operations, preparation of the nasal 
 passajjes by a course of conservative treatment is essential to success. 
 This usually conii)rises removal of the anterior portion of the middle 
 turbinate bone which almost invariably is thickened and interferes 
 with intranasal drainage. In cases of patients acutely ill it often is 
 better to do an operation which is incomplete from the specialist's 
 standpoint, consisting merely in securing adequate drainage by the 
 most accessible route, and to postpone the ideal radical operation to 
 another occasion, as in the parallel cases of acute mastoiditis (p. 632). 
 Drainage tubes or gauze, employed in these nasal operations never 
 should be allowed to remain in place more than forty-eight hours. 
 Careful after-treatment, preferably- conducted by a rhinologist, is 
 necessary to complete the cure. 
 
 The maxillary antrum communicates with the nasal cavity through 
 its middle meatus, and the opening is some distance above the floor 
 of the sinus so that drainage is very imperfect. Infection may follow 
 nasal disease or be due to extension upward from a carious tooth. 
 When conservative measures fail, the surgeon may break through the 
 outer wall of the nasal fossa, in the inferior meatus, thus establishing 
 drainage at the level of the floor of the antrum. This may be done in 
 emergency by firm pressure with the blunt ends of the blades of scissors 
 curved on the flat. Usually it is preferable to open the maxillary sinus 
 by gouge and mallet through the canine fossa, after incising and 
 reflecting the mucous membrane and periosteum. A large opening 
 in the outer wall of the sinus should be made, and its cavity should 
 be cleared of polypi, necrotic bone, etc. Then the inner wall of the 
 sinus is broken down as far as the level of its floor, working across its 
 cavity. The nasal mucous membrane is preserved, is formed into a 
 flap attached along the floor of the nose, and is turned outward to 
 cover the floor of the maxillary sinus, which is thus freely drained into 
 the inferior meatus of the nose. This mucous flap is held in place by 
 packing introduced from the nasal cavity, and the incision in the 
 alveolar tissues is closed by suture. 
 
 The frontal sinus is readil}' exposed by applying a small trephine 
 just to one side of the glabella. As the size of these sinuses is extremely 
 A'ariable, not only in different individuals, but also on the two sides 
 of the same individual, the surgeon always should make an opening 
 which is small and close to the root of the nose, so as to run no danger 
 of entering the cranial cavity. This opening may then be enlarged 
 with gouge or rongeur. A tract for drainage into the middle meatus 
 of the nose can be made by enlarging the infundibulum with curette. 
 Such drainage, by a tube passed from the inner angle of the frontal 
 incision down into the nose, is sufficient in emergency. Killian's 
 operation, described below, is preferable as a method of radical cure. 
 
 The anterior ethmoidal cells frecpiently are diseased along with the 
 frontal sinus, as they usually drain into the upper part of the infun- 
 
SURGERY OF THE JAWS 057 
 
 dil)iiluni; iiiid tlu-y ;irc best cviicuatrd across tlio opcm-d t'ruiital sinus. 
 Tlio middle and posterior ethmoidal cells drain into the middle meatus 
 and till' superior meatus, respectively. They may he reached hy resec- 
 tion of the OS planum, after exposing,' the inner wall of the orbit. 
 There may be a fistula in this situation, or even an abscess between 
 the OS plaiuim and the eye-ball. Drainage into the nasal cavity and 
 from the i-xternal wound is provided for. For radical cure, Killian's 
 oi)eration is preferable. 
 
 The sphenoidal sinus seldom can be drained elVectively by the intra- 
 nasal route, and as the ethmoidal and frontal sinuses frequently are 
 involved also, the method of treatment for radical cure usually 
 employed now is that known as Killian's Operation (1902), which 
 involves an approach across the frontal sinus. This includes removal 
 of the anterior wall of the frontal sinus and of its floor (the roof of the 
 iimer part of the orbit), leaving a bridge of bone (supra-orbital ridge) 
 l)etween these two openings to support the soft parts when sutured 
 and thus prevent deformity. After evacuating the frontal sinus, and 
 thoroughly exposing all its angles, the frontal process of the superior 
 maxilla is removed. (This should be done without injury to the 
 mucosa of the nasal cavity, which is to be preserved as a flap to line 
 the excavated frontal sinus and establish a free communication 
 between this cavity and the nose.) The ethmoid cells which are thus 
 exposed are then cleaned away, and the anterior wall of the sphenoidal 
 sinus is removed by gouge or gouge forceps. Removal of part of the 
 nasal bone of the" side affected may be necessary to secure better 
 exposure. The flap of nasal mucosa finally is turned outward across 
 the lower wall of the large cavity, and this is Ughtly packed with gauze 
 which emerges into the nasal fossa. The external wound is then 
 completely sutured. 
 
 SURGERY OF THE JAWS. 
 
 Alveolar Abscess.— Aheolar abscess almost always is secondary 
 to dental disease. Before the stage of suppuration, peridental inflam- 
 mation is denoted by tenderness, which usually is relieved by firm 
 pressure on the gum, accompanied by moderate swelHng. At this 
 stage proper disinfection of the root canals of the teeth, which are 
 infected from the cavity in the crown, usually causes arrest of the pro- 
 cess. Later the entire side of the jaw may be swollen, and tenderness 
 is exquisite. Sometimes the pus escapes at the side of the tooth, but 
 in many cases it spreads beneath the periosteum of the jaw, and 
 unless promptly evacuated, osteomyelitis and necrosis may result, or 
 in the upper jaw% involvement of the maxillary sinus. Occasionally 
 the pus breaks through the skin below the l)ody of the mandible 
 (Fig. ()99), or will form an abscess in the cheek (Fig. 700). Secondary 
 infection of the salivary glands or of the cervical lymph nodes may 
 occur. 
 42 
 
658 
 
 SURGERY OF THE FACE, MOUTH, A\D XECK 
 
 Treatment. — Early free incision of the alveolar border, down to the 
 bone, followed by detergent mouth washes usually is promptly curative, 
 and even if no pus is found this incision quickly relieves pain and 
 markediv accelerates recoverv. 
 
 Fig. 699. — Alveolar abscess of lower 
 jaw, pointing over body of mandible. 
 Four days after extraction of tooth. 
 Episcopal Hospital. 
 
 Fig. 700. — Abscess of left cheek, fol- 
 lowing pulling of teeth on upper and 
 lower jaw. thirteen days previously. 
 Episcopal Hospital. 
 
 Acute Osteomyelitis of the jaws is not common even in the mandible, 
 and in the maxilla is decidedly rare. The general septic symptoms 
 render differentiation from alveolar abscess easy. 
 
 Treatment. — Treatment consists in free incision, both inside and 
 outside the mouth. The inflammation may be confined to the alveolar 
 border, but it is better to open the body of the jaw by trephine or gouge 
 if there is any doubt as to the limits of the disease. Free drainage 
 is the most essential factor. 
 
 Necrosis of the Jaws affects the mandible in most cases, and follows 
 acute osteomyelitis, or may be due to phosphorus poisoning, with 
 subacute or chronic onset. In the latter instance the disease seldom 
 appears until the patient has been working in phosphorus for several 
 years, and it may not appear for several years after the patient has 
 quit his work in phosphorus. Phosphorus poisoning produces changes 
 of a chronic ossifying nature in the periosteum in all parts of the 
 body, resulting in increased density of the bone, decrease in the 
 size of the marrow cavity, and lessened circulation. These changes 
 are particularly marked in the mandible. If secondary infection does 
 not intervene, as in the mandible it usually does from carious teeth, 
 the later stages of the process (rarefaction and pathological fracture) 
 are seen. Workers in phosphorus should have their teeth inspected 
 and cleaned by a competent dentist, at frequent intervals. Necrosis 
 
SURGERY OF THE JAWS 
 
 659 
 
 of tilt' jaws ocfasioiially results from the constitutional effects of 
 arsenic jxiiftoninc/, or from mercurial stomatitis. 
 
 Treatment. — Treatment consists in providing; free drainage hy 
 incision of the soft parts and involucrum, when the latter is j)resent. 
 (ireat conservatism should be exercised in extraction of scfjuestra. 
 It is best to wait initil they are freely movable by probes introduced 
 through nei«;hboring cloacae, and until the involucrum has developed 
 sufficiently to maintain the form of the jaw. Though the teeth 
 usually are lost, the ultimate outcome as regards function usually 
 is satisfactory. 
 
 Ankylosis of the Temporo-maxillary Joint may be unilateral or 
 bilateral, but even unilateral involvement renders the jaw immovable. 
 The condition may result from 
 various forms of arthritis or from 
 fracture of the condyle; or false 
 ankylosis may occur from peri- 
 articular contractures, due to cica- 
 trices from burns, etc. If the 
 ankylosis occurs before full de- 
 velopment of the mandible, retrog- 
 nathism, or micrognathy is the 
 result (Fig. 701), from loss of 
 function. In unilateral ankylosis 
 the affected side of the mandible 
 seems smaller than the sound side, 
 but stands out normally from the 
 neck, whereas the healthy side 
 appears flattened; the chin usuall\' 
 is deviated toward the affected 
 side (Kirstein, 1910). 
 
 Treatment. — Some form of arthro- 
 plasty (p. 471) is necessary to re- 
 store motion. The joint is best ex- 
 posed by turning down from above 
 a skin-flap with temporary resec- 
 tion of the zygoma (Lilienthal, 
 
 191 1 J. The condyle of the mandible is then excised, and a flap turned in 
 from the temporal muscle or masseter. By turning down the zygoma, 
 with attached masseter muscle, any damage to the facial nerve, 
 parotid gland, and duct, is avoided. The periosteal insertion of the 
 external pterygoid muscle should be preserved. The older operations 
 of resection of a wedge from the body of the mandible in front of the 
 angle seldom succeeded in restoring permanent motion. For false 
 ankylosis from cicatricial contractures a plastic operation is necessary. 
 Murphy (1913) uses a flap of mucous membrane from the hard palate. 
 The mandible may be lengthened by osteoplastic operation on both 
 sides, dividing the body in sigmoid fashion and sliding the lower 
 segment forward. 
 
 Fig. 701. — Retrognathism from anky- 
 losis of jaw due to post-scarlatinal arthri- 
 tis in infancy. Xow eight j-ears old. 
 Orthopaedic Hospital. 
 
660 
 
 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 Facial Hemiatrophy is a very rare condition of obscure origin, but 
 one whose existence should be known to the surgeon, for diagnostic 
 purposes (Fig. 702). The atrophy afi'ects bones as well as soft parts. 
 
 It may be associated with neuritis 
 of the trigeminal nerve, but usually 
 is not painful. Neurologists treat 
 it by electric currents and general 
 hygienic measures. 
 
 Tumors of the Jaw. — These may 
 arise from the alveolar border or 
 from the body of the bone. 
 
 Tumors of the Alveolar Border. 
 — There are three of these alveolar 
 growths of considerable frequency: 
 Epulis, Ossifying Periosteitis, and 
 Carcinoma. 
 
 1. Epulis. — Epulis, a connective 
 tissue tumor, is the most frequent 
 growth of the alveolus. Pathologic- 
 ally it is either (a) a fibroma or an 
 angeio-fibroma, or (b) a tumor con- 
 taining giant cells, resembling a 
 myeloma or myeloid sarcoma. This 
 appears to be the only region in 
 the body where giant cells spring 
 from periosteum. Epulis seems 
 to be more nearly related to in- 
 flammatory processes than to true neoplasms. The giant-celled form 
 often arises above an old root or beside a decayed tooth, and is red- 
 dish brown in color; but the fibrous form may occur where the teeth 
 appear normal, and is whiter in color. Epulis is painless, but in 
 spite of this fact often has been mistaken for an alveolar abscess. It 
 occurs in children or young adults, is soft and elastic, but does not 
 fluctuate. Ulceration may occur eventually, but is very long delayed. 
 Treatment. — Treatment consists in local extirpation by knife and 
 gouge forceps, through healthy tissues. The raw surface left should be 
 seared with the actual cautery. Recurrence may take place if the 
 surgeon is too conservative. Yet even after repeated recurrence no 
 metastasis occurs. It never is necessary to excise the whole thick- 
 ness of the bone; removal of the portion of the alveolus afi'ected is 
 sufficient. 
 
 2. Ossifying Periosteitis forms a diffuse bony enlargement of the 
 alveolus. It may be due to chronic infection (as pyorrhea alveolaris). 
 Subperiosteal resection may be done, without fear of recurrence. 
 
 3. Carcinoma. — Carcinoma is commoner on the upper (Fig. 703) than 
 the lower jaw (Fig. 704). It is sufficiently distinguished from epulis 
 by its occurrence only in older patients, by its early ulceration, the 
 marked induration of the borders of the ulcer, and the ultimate 
 
 Fig. 702. — Left facial hemiatrophy. 
 Male twenty-six years old. Duration 
 ten months. No injury, but he was a 
 "boxer" and deformity was mistaken 
 for that due to impacted and united 
 fracture of ascending ramus of lower 
 jaw. Notice over-lapping of teeth. 
 Episcopal Hospital. 
 
SURCERY OF THE J.IU'.S 
 
 GGl 
 
 involvemont of the lymi)li muies. Extirpiition, tojrcthcr with wide 
 excision of the lymphatics of the same si(h' as the lesion, is the i)roi)er 
 treatment. 
 
 Fig. 7U::i. — Lareiiioiiia oi uiipcr jaw. Age 
 seventy-three years; duration sLx months, 
 now inoperable. Was struck on this side of 
 mouth one year ago by handle of "release" 
 while running engine. Episcopal Hospital. 
 
 Fig. 704. — Recurrent carcinoma of 
 inferior maxilla. Partial excision of 
 mandible in September, 1906. Pho- 
 tograph March 1908. Now inoperable. 
 (Dr. H. C. Deaver's case.) Episcopal 
 Hospital. 
 
 Tumors of the Body of the Jaw.— Some of these are benign, and 
 some are malignant. Among the former are dentigerous cysts, espe- 
 cially the adamantinoma. These were discussed at p. 112. Of the 
 malignant tumors {sarcomas) there are various forms. Until recently 
 the giant-celled form of epulis, affecting the alveolus, was classed as 
 a sarcoma. True sarcoma may affect the body of either the upper 
 or lower jaw. Usually it is periosteal in origin, and grows as a firm or 
 even a bony tumor. It does not present egg-shell crackling, which is 
 common in the admantinoma, and occurs in older patients than those 
 in whom dentigerous cysts usually are seen. According to Bloodgood 
 sarcoma of the lower jaw in front of the angle usually is of a less malig- 
 nant nature than the forms which occur at the angle and rapidly invade 
 the ramus. The former (less malignant) growths are "mixed sar- 
 comas," that is, partly bony, fibrous, or myxomatous, and are rare 
 after the age of twenty-five years. The more malignant varieties, 
 which are rare before the age of twenty-five years, are spindle- and 
 round-celled sarcomas. These latter quickly invade the soft parts, 
 extending in the upper jaw to the antrum (where, indeed, they may 
 originate), to the orbit, and to the temporo-maxillary fossa; and in 
 the lower jaw invading the pharynx and soft structures of the neck. 
 The differential diagnosis is best made from an excised specimen. 
 
662 
 
 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 Treatir.ent. — In the less malignant forms of sarcoma, the surgeon 
 aims to remove the entire growth, with a small margin of healthy 
 tissue on all sides. In the lower jaw this usually necessitates a resec- 
 tion of the entire thickness of the bone, though very occasionally the 
 ah'eolar border may be left as a splint to maintain the form of the bone. 
 In the upper jaw it usually is possible to preserve the or})ital jjlate, 
 and often the hard palate also. It is doubtful whether any operation, 
 even the most radical, is of any use whatever in the more malignant 
 forms of sarcoma. 
 
 Excision of the Superior Maxilla. — The typical operation^ though 
 seldom done at present for tumors arising in the maxilla itself, some- 
 times is required as a preliminary to the 
 removal of growths in the naso-pharynx. 
 Preliminary ligation of the external carotid 
 artery is advisable if the operation is for 
 exposure of such a tumor. The incision 
 shown in Fig. 705, enters the nostril and 
 outlines a flap which is reflected outward, 
 the knife being kept close to the peri- 
 osteum. The mucous membrane of the 
 hard palate is divided in the median line, 
 and the attachment of the soft palate to 
 the bone severed transversely. The mu- 
 cous membrane of the gingi^'o-labial fold 
 is divided clear of the disease, and that in 
 the floor of the nose is divided in the 
 median line. After extraction of the cen- 
 tral incisor tooth on the involved side, the alveolus and palate are 
 divided by a phalangeal saw (Fig. 139, 6), introduced through the 
 nostril. The tissues of the orbit are then displaced upward, the si)heno- 
 maxillary fissure is identified, and the attachment of the maxilla to 
 the malar bone is divided wdth saw. Then the nasal process of the 
 maxilla is divided from orbital to nasal cavit>% and the bone is grasped 
 in lion-jawed forceps and pulled downward, any remaining attachments, 
 including the junction of the pterygoid processes with the maxilla, being 
 severed with bone-cutting forceps or chisel. Hemorrhage is then con- 
 trolled, if necessary by the actual cautery. The mucosa of the cheek 
 is then sutured to that of the palate, and the skin wound closed with 
 interrupted sutures, after packing it loosely with iodoform gauze, which 
 is made accessible through the nostril. Frequent syringing through the 
 nostril or any opening in the roof of the mouth is required during con- 
 valescence. Temporary resection of the superior maxilla is done by the 
 same skin incision, but the flap is not separated from the bone; this 
 is divided as above described except at its malar attachment, which is 
 used as a hinge, after fracture by leverage outward. 
 
 Excision of the Inferior Maxilla. — The typical operation involves 
 only half the mandible. An incision is made from the middle of the 
 lower lip down to the hyoid bone, and from this point back as far as 
 
 Fig. 705. — Fergusson's incision 
 for excision of upper jaw. 
 
SURGERY OF THE TONSIL AND PHARYNX 
 
 ()()3 
 
 the aiifilo of tlu' jaw, thv submaxillary structures arc dissectcl tree, 
 and the soft part's arc separati'd from the outer surface of the bone, 
 respecting,' the branches of the facial nerve, but liKatinf^ the facial and 
 the linunial arteries and veins. :\iost of the external surlace ot the 
 ranms is thus exposed. The symphysis is then divided with saw and 
 the structures of the floor of the mouth cut with scissors, from before 
 backward. An incision is then made alon^' the mucous membrane 
 on each side of the ascending ramus of the jaw; the bone is forcibly 
 depressed, and the insertion of the temporal muscle into the coronoid 
 I)rocess is divided with scissors. The jaw is then turned somewhat 
 outward, and the ptcryj;-oid muscles cut dose to their insertions. 
 The liiii^nial nerve should be preserved if i)()ssible, but, of course, 
 the inferior dental must be sacrificed. The temporo-maxillary joint 
 mav then be opened, the few^ remaining attachments severed, and the 
 bone removed. After careful control of all hemorrhage, the pterygoids 
 are sutured to the masseter muscle, and the mucous menil)rane of the 
 cheek united to that of the floor of the mouth. Finally the skin 
 wound is closed, with provision for drainage externally. Partial 
 ('.vci,v(»i involves removal only of the portion of bone afl'ected, after 
 its division in front of and behind the growth. 
 
 Prosthesis after Excision of the Inferior Maxillary Bone.—U the 
 periosteum can be preserved, a shell of bone sufficient to prevent exces- 
 sive deformitv may be formed in time. While the wound is healmg 
 the remaining portions of the bone should be held in proper position 
 bv stout silver wire, used as a bridge across the gap left b\- excision 
 of the diseased portion. A sinus usually persists until the wire is 
 remo^•ed, but bv that time the bone may be sufficiently firm. Claude 
 :\Iartin, of Lyons, since 1878, has employed after excision of either 
 upper or lower jaw, a temporary prosthesis made of hard rubber, pre- 
 viouslv constructed to fit into the contemplated defect. This pros- 
 thesis 'is riddled with channels, and though it is implanted into the 
 wound through the buccal aspect (no attempt being made to close 
 an^'thing but the skin), the wound and the appliance may in almost 
 alf cases be kept clean until healing occurs by irrigation through 
 its numerous channels. When healing is complete a permanent 
 prosthesis is constructed. 
 
 SURGERY OF THE TONSIL AND PHARYNX. 
 
 Peritonsillar Abscess or Quinsy usually is a sequel of parenchy- 
 matous am^■gdalitis. The systemic symptoms of sepsis may be marked. 
 Localh-, in addition to the signs of the preceding tonsillitis, may be 
 observed a diffuse swelling of the soft palate at the upper border of 
 the tonsil. At no time is a distinct sense of fluctuation obtainable. 
 Earlv evacuation is the only satisfactory treatment. Thrust a grooved 
 director through the most prominent part of the swelling (usually 
 through the soft palate), after painting it with 10 per cent, cocain 
 (Fig. 706). The tract made by the grooved director may be enlarged 
 
664 
 
 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 Fig. 706. — Puncture of peritonsillar abscess 
 through soft palate. 
 
 by inserting the closed points of a pair of dressing forceps, and with- 
 drawing the instrument with the bla(h^s ()})ened. Tiic reHef is innne- 
 diate, and under the use of simple alkaline mouth washes con\al- 
 escence usually is established in twenty-four to thirty-six hours. 
 
 If a peritonsillar abscess is 
 left to burst of itself, it may 
 do so during sleep, and has 
 caused death from suffoca- 
 tion. In very young children 
 it is better to open it in the 
 head-low position. 
 
 Malignant Tumors of the 
 Tonsil. — Either carcinoma 
 or sarcoma may occur in the 
 tonsil . Diagnosis is not easy. 
 Any unilateral tonsillar en- 
 largement in an adult should 
 be regarded with suspicion. 
 The possibility of syphilitic 
 lesions of the tonsil (chan- 
 cre and ulcerated gumma) 
 should be kept in mind, and 
 their presence excluded by the history of the case, the existence of 
 evidences, past or present, of the disease elsewhere in the body; as 
 well as by the use of laboratory and therapeutic tests. In most cases 
 a specimen of the growth should be excised for microscopic study. 
 In carcinoma the diagnosis usually is easily made by this means, 
 but in sarcoma the histological picture may not be convincing. 
 
 Symptoms. — The symptoms are chiefly those of obstruction, in 
 sarcoma, with pain on deglutition; the lymph nodes seldom become 
 enlarged until late in the disease, after ulceration has occurred. 
 Local extension to the palate and pharynx is much more common in 
 carcinoma, and in this affection the submaxillary and deep cervical 
 lymph nodes are involved early, though not palpably so for a number 
 of weeks. 
 
 Treatment. — If the diagnosis is made very early in the disease, 
 by means of microscopic study, it may be possible to enucleate the 
 tonsil from within the mouth. Usually, however, and particularly 
 in the case of carcinoma, the growth should be approached from the 
 neck. In lateral 'pharyncjoiomy an incision is made from the mastoid 
 well forward under the body of the jaw; after clearing the submaxil- 
 lary and cervical regions, the facial artery is ligated close to its origin, 
 so as to control its tonsillar and ascending palatine branches; the wall 
 of the pharynx is incised on a sound introduced through the mouth, 
 and the diseased area excised with scissors. Temporary resection of 
 the mandible may be requisite. Approach to the tonsil, the epiglottis, 
 and the pharynx may also be gained by suprahyoid pharyngotomy 
 (Jeremitsch, 1895; von Hacker, 1906); in this operation a transverse 
 
SURCERY OF THE MR PASSAGES 005 
 
 incision, coiwi^N t'onvard, and al>(>ut throe or four inches I()nf,^ is niach' 
 uhovc the hyoid hone, and all tlie inusck'S passing ujjward from tills 
 bone are divided, inchiding both genio-hyoids, the mylo-hyoid. 
 genio-hyot;"lossus, and hyo-<j;h)ssns; sometimes also the stylo-liyoid 
 and anterior helly of the (Hgastric on the side of tiie lesion. Enon<i,h 
 tissue should be left attached to the hyoid bone to facilitate subse- 
 quent suture. By hyperextension of the neck, and pulling the chin 
 upward, wide exposure of the base of the tongue and the lateral pharyn- 
 geal walls is secured. Usually the facial and lingual arteries on the 
 more diseased side must be ligated; the liy])oglossal nerve should be 
 preserved if possible. Subhyoid pharymjuioiny (\'idal de Cassis, 1820; 
 Sklifosovsky, 1802) is a somewhat similar operation, but there is more 
 danger of injuring the su])erior laryngeal nerve, without compensating 
 advantages. When the malignant growth has been excised, the severed 
 cer^'ical tissues are carefully re-united by many rows of buried sutures, 
 and the wound is freely drained. These operations are dangerous, 
 seldom employed, and difficult even for skilled operators with accu- 
 rate anatomical knowledge. 
 
 If the case is inoperable, palliative measures, such as the " starva- 
 tion" method of Dawbarn (p. 055), may be tried, with the use of the 
 x-ray, and, in the case of sarcoma, of Coley's fluid. 
 
 Tumors of the Naso-pharynx.- — These usually are soft fibromas, 
 occur in young adults from fifteen to twenty-five years of age, and in 
 many cases assume a character which clinically is malignant, though 
 microscopical examination rarely shows a typical sarcoma. They 
 spring from the submucous tissues at the base of the skull, and grow 
 into the nasal passages, invade the maxillary sinus, the orbit, the 
 temporal fossa, and may open even the cranial cavity. Occasionally 
 they seem to spring from the antrum and grow backward into the 
 naso-pharynx. Unless removed, death is practically certain from 
 obstruction to respiration and deglutition. The growth is apt to 
 recur after partial removal, and complete extirpation is a serious and 
 often a bloody operation, demanding usually excision of the superior 
 maxilla (p. 002) to gain access to the growth, even if this bone is not 
 itself invaded by the disease. Preliminary ligation of the external 
 carotid artery is advisable, and the actual cautery may be required 
 to check the bleeding even after this precaution. 
 
 SURGERY OF THE AIR PASSAGES. 
 
 Foreign Bodies. — Foreign bodies are especially apt to enter the 
 larynx, trachea, or bronchial tubes in young children, wdio thoughtlessly 
 place various objects in the mouth, and by a sudden act of inspiration, 
 in laughing or coughing, draw them into the larynx. In anesthetized 
 patients, or those in a drunken stupor, vomited matters may be simi- 
 larly aspirated into the air passages. Severe paroxysms of choking 
 ensue, but very rarely does rapid death from asphyxia occur. Apart 
 from asphyxia, the chief danger is due to secondary pulmonary inflam- 
 
666 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 mation. Occasionally a foreign body is arrested in the larynx, but in 
 most instances it passes down into the trachea, and thence usually 
 into one or other })ronchus. 
 
 Symptoms. — Symptoms depend on the site of the foreign body, and 
 on the time which has elapsed since the accident. The first symptoms, 
 or those of obstruction, seldom last very long. They are succeeded 
 by those of irritation, denoted by a short croup\' cough, with retro- 
 sternal pain, and later by mucous or bloody expectoration; paroxysms 
 of dyspnea occur from time to time when the foreign body is forced 
 upward into the larynx. If impacted in the larynx, symptoms of 
 obstruction persist, and there usually is aphonia. If impacted in a 
 bronchus, or if immovably fixed at any point b\- a sharp projection 
 catching in the mucous memV)rane, the symptoms of irritation are not 
 very marked; and auscultation over the region of the lung obstructed 
 usually detects very weak or absent respiratory murmur, but no dulness 
 is found on percussion until inflammatory changes arise. If the for- 
 eign body moves freely about in respiration, the symptoms of irritation 
 are very pronounced, and occasionally the foreign body can be heard 
 flapping about. 
 
 Diagnosis. — The diagnosis in small children must be made from 
 " croup'" or diphtheria, and in the absence of a clear history, and where 
 there is no evidence of diphtheritic membrane in the pharynx, this is 
 difficult, without laryngoscopic examination. When a foreign body is 
 present dyspnea occurs particularly in expiration, while in laryngeal 
 obstruction from other causes, inspiratory dyspnea is found. ^lore- 
 over, if the foreign body is sufficiently dense ( a pebble or some metallic 
 toy), its presence will be revealed by the .r-ray. In the case of foreign 
 bodies impacted in the pharynx or esophagus there rarely is so much 
 dyspnea, and swallowing will be difficult or impossible. A foreign 
 body in the pharynx usually can be reached b\' a finger introduced 
 into the mouth. 
 
 Treatment. — 1 . In emergencies, any physician may open the trachea 
 and extract the foreign body if it can be found. If impacted in the 
 larynx, high tracheotomy or crico-thyrotomy should be preferred. 
 In other cases low tracheotomy is better. Even if the foreign body is 
 not found it is more apt to be discharged spontaneously through a 
 tracheotomy wound than by the natural passages. 
 
 2. When there is no emergency, the services of a skilled laryngologist 
 should be procured. He may be able, by means of a bronchoscope 
 introduced through the mouth (upper bronchoscopy) to see and extract 
 the foreign body (Fig. 707). If it is situated too low to be reached 
 successfully from above, the same method may be employed, the 
 instrument being introduced through a "low tracheotomy" wound 
 (p. 670), the procedure then being known as lower bronchoscopy (Fig. 
 708). Bronchoscopy was introduced by Killian in 1897. and has been 
 highly developed by Guisez in France, and by Che^•alier Jackson in 
 this country. R. T. ^Morris and Huber (1910) have employed it very 
 successfully in conjunction with fluoroscopic inspection of the foreign 
 
Sl'RCERY OF TflE MR I'ASSAdES 007 
 
 body (luring tlie inaii<ruvms of extraction. (Icncral anesthesia usually 
 is recjuired. In early cases upper l)ronchoscoi)y may he successtul, 
 but when i)nlnionary complications exist lower l)ronchoscoi)y is to he 
 preferred. 
 
 Fig. 707. — Upper bronchoscopy. 
 
 Fig. 708. — Lower bronchoscopy. 
 
 Fracture of the Larynx is rare. The thyroid is the cartilage most 
 often involved. :\lichel (1910) has studied 40 cases recently reported. 
 Among these there were 17 deaths. Seven of these patients died 
 suddenly, without operation, at periods varying from a few hours to 
 six davs after the accident. The mortality in non-operative cases is 
 42 per cent. In ver\- severe injuries, where the fracture is compound 
 internallv (hemoptvsis, threatening asphyxia from edema of the glottis) 
 tracheotom>- should be done, and the deformity corrected. In very 
 mild cases," no operation is required, it being sufficient to appb" a 
 light immobilizing dressing. In intermediate cases, especially if there 
 is any emphysema, tracheotomy should be done as a precautionary 
 
668 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 measure, since experience shows that in such cases sudden death is apt 
 to occur from edema of the glottis. 
 
 Edema of the Glottis. — Above the true vocal cords there is abun- 
 dance of loose areolar submucous tissue, prone to edema from trauma 
 or infection. Below the vocal cords the mucosa is tightly applied to 
 the cartilage. The symptoms of edema of the glottis usually develop 
 very suddenly and often quite unexpectedly. They are those of 
 asphyxia. Treatment, which must be immediate, consists in crico- 
 tliyrotomy or high tracheotomy (p. 670), 
 
 Tumors of the Larynx. — These belong rather to the province of the 
 laryngologist than to that of the general surgeon, except when external 
 operations are required. In any case it is well for surgeon and laryn- 
 gologist to act in consultation. 
 
 The most frequent benign tumor is the papilloma. It may occur in 
 patients of any age, but is most frequent in young adults. Early 
 symptoms of hoarseness, with recurrent attacks of laryngitis, finally 
 will be followed by those of respiratory obstruction. The diagnosis 
 is confirmed by inspection of the larynx through a mirror introduced 
 above its superior aperture (laryngoscopy). Benign growths usually 
 are pedunculated; ulceration or bleeding points to mahgnancy. 
 Pedunculated growths usually may be removed bj' intra-laryngeal 
 methods, in the hands of a specialist. Papilloma is very apt to recur, 
 but other forms of benign tumors rarely return. The performance of 
 tracheotomy, with the use of a tracheal tube sometimes has served 
 to prevent recurrence, by putting the larynx completely at rest. 
 
 Carcinoma. — Carcinoma is the most frequent malignant tumor. It 
 is said to be rare as a sequel of papilloma. Sarcoma is very rare. 
 In many cases the growth involves the larynx secondarily, having 
 originated in the tongue, pharynx, or esophagus ; this form is described 
 as extrinsic carcinovm of the larynx, as distinguished from intrinsic 
 carcinoma, arising primarily within the larynx. The symptoms are 
 the same as in benign growths, but the patients are older (it is rare 
 before fifty years), there is more pain, and sometimes there is sponta- 
 neous bleeding. The diagnosis is made by laryngoscopy, and if neces- 
 sary by microscopical examination of an excised portion of the growth. 
 The disease usually is more extensive than it seems. Tuberculosis 
 and syphilis have to be considered, but usually may be excluded by 
 the history of the case, by clinical examination, and by laboratory 
 tests. The pjrognosis of carcinoma of the larynx is bad. ^Yithout 
 operation death usually occurs within three years, and it is a very 
 painful death. Treatment should be radical whenever possible, and it 
 is best accomplished h\ external operation. 
 
 OPERATIONS ON THE AIR PASSAGES. 
 
 Intubation of the Larynx. — This operation, introduced by O'Dwyer 
 in 18tS,5, consists in the introduction into the larynx, by special instru- 
 
OPERATIONS ON THE Alii PASSAGES 
 
 ()()9 
 
 ments passed throii^^li the iiKtutli, ol' a hollow tiilK- wliicli is allowed 
 to remain, suspended from the false vocal cords, until the symptoms 
 of laryiij,a'al stenosis, for which the operation was (h)ne, have sub- 
 sided. It is employed almost solely for larynj,'eal obstruction resulting 
 from diphtheria. The arnuimentarium comprises a set of hollow hard 
 rubber tubes of various sizes suitable for any age up to twelve years. 
 The approximate size is determined beforehand by means of a scale. 
 Each tube is provided with a hole at its ui)per end through which a 
 long thread is passed; the thread is left hanging out of the patient's 
 mouth and enables the tube to be quickly withdrawn if necessary. 
 The tube is tiien fitted over the obturator, which is screwed securely 
 to the introducer. A gag is placed in the left side of the mouth, and 
 the child (not anesthetized) is 
 held upright in the nurse's 
 arms, with head steadied and 
 slightly extended. The surgeon 
 then introduces his left fore- 
 finger and draws the tip of the 
 epiglottis forward. The intro- 
 ducer is then passed backward 
 by the right hand and the tip 
 of the tube is guided into the 
 larvnx by the fingers of the left 
 hand (Fig. 709). The tube is 
 then quickly pushed off the 
 obturator by means of the slid- 
 ing shaft on the introducer, 
 and the latter with the obtur- 
 ator still attached is with- 
 drawn. The thread fastened 
 to the tube is left hanging out 
 
 of the mouth, until it is certain that the tube will be well borne. 
 If the tube has been passed into the esophagus by mistake, it 
 should be withdrawn at once, cleansed, and properly reinserted. If 
 dyspnea is not relieved when the tube is in the larynx, a larger tulje 
 should be inserted. If the tube is well borne, the thread may be 
 removed after a few hours. When necessary the tube may then be 
 removed by the extractor, reversing the steps employed in its intro- 
 duction. 
 
 The mortality due to the operation itself is very inconsiderable, 
 but death may occur in spite of the operation. Intubation should be 
 preferred to tracheotomy in all cases in which it is applicable. When 
 it fails to relieve the obstruction, tracheotomy may still be done, 
 and a tube inserted below the obstruction. 
 
 In cutting operations upon the air passages the patient should be 
 in the "hanging head position" (Fig. 676); this not only renders the 
 parts more accessible, but avoids so far as possible aspiration of blood 
 or gastric contents. In cases where partial asphyxia is present, no 
 
 Fig. 709. — Intubation of larynx. 
 
670 SURGERY OF THE FACE, MOUTH, AA'D NECK 
 
 anesthetic is reciuired; in others local anesthesia nsiially is snfficient 
 except where the soft parts have been inva(le<I hy malignant disease. 
 Shortly before extensive operations (thxrotomy, laryngectomy) a 
 hypodermic injection should be given of morphin (gr. I) and atropin 
 (gr. tjtt), to diminish secretion and paralyze inhibitory impulses. 
 Local use of cocain, even when a general anesthetic is employed, is 
 advisable for the latter purpose also. 
 
 Crico-thyrotomy, in which an incision is made in the crico-thyroid 
 membrane, occasionally is done for acute laryngeal obstruction in 
 adults. The wind-pipe is here most accessible, and in emergencies 
 there is no other method by which it may be so quickly opened. But 
 there is some danger of injuring the recurrent laryngeal nerve, and as 
 the larynx itself is opened it is not considered a proper operation for 
 diphtheritic obstruction, as the false membrane may extend below the 
 seat of operation. But in cases of edema of the glottis this objection 
 does not apply. Xo anesthetic is required. The surgeon fixes the 
 cricoid cartilage between the thumb and finger of his left hand, and 
 makes a small transverse incision in the skin over the crico-thyroid 
 space. The sterno-hyoid muscles are then separated, and the blade 
 of the knife is entered transversely through the crico-thyroid mem- 
 brane. If the crico-thyroid artery is wounded, it should be clamped 
 and tied before opening the larynx. Occasionally it is of large size. 
 A tracheotomy tube is then introduced, and the after-treatment con- 
 ducted as in a case of tracheotomy. 
 
 Tracheotomy. — The trachea may be opened either above (high 
 tracheotomy) or below the isthmus of the thyroid gland (loic trache- 
 otomy). Usually two or three rings are accessible above, and as many 
 below the isthmus. The high operation usually is to be preferred if 
 the indication is laryngeal obstruction, but, as already mentioned, low 
 tracheotomy is preferable for the removal of a foreign body in the 
 bronchi. The higher the trachea is approached, the nearer does it 
 lie to the surface of the neck ; and in the suprasternal region access to 
 it is obscured by numerous veins, which are markedly engorged in 
 cases of respiratory obstruction, and render the operation much more 
 difficult (Fig. 710). Xo anesthetic is required. Partial asphyxiation 
 renders the patient almost insensible to pain, and the first incision cuts 
 all the sensory nerves. Most surgeons still employ a longitudinal skin 
 incision, but I believe with O. Franck a transverse one is better, as 
 it is less liable to subsequent infection, gives better exposure and 
 leaves an inconspicuous scar. If the skin is pinched up in the 
 fingers, the anterior jugular veins do not come with it, and there is 
 almost no bleeding. The interspace between the sterno-hyoid mus- 
 cles is identified, and these as well as the underlying sterno-thyroids 
 are separated, exposing the trachea. This is then fixed in the wound 
 by a sharp tenaculum. Unless this precaution is taken it may be 
 very difficult to cut the cartilages, especially in an adult, as the 
 knife is apt to push the trachea deeper into the neck or to one side. 
 Two or possibly three cartilages are then divided, in the long axis 
 
OPERATIONS ON TIIK AIR PASSAGES 
 
 iu 
 
 of the trachea, strictly in the median line, and a tracheal dilator 
 (Fiji. 711) is introduced. Or the trachea may be opened trans- 
 versely, i)et\veen two rin<,'s; it will gai)e, owin*,' to the hyperextension 
 of the neck. In this way the oi)eration may he completed with no 
 other instrument than the knife. 
 The operator shoukl take care, 
 esi)ecially in cases of diphtheria, 
 that the violent ])aroxysms of 
 coufjhing, which follow oi)enino; the 
 trachea, do not spatter his face with 
 false niemhrane. Any membrane 
 presentin<i in the wound should be 
 carefully withdrawn. A tracheof- 
 omy tube (Fig. 712) is then inserted, 
 and fastened in place }\v tapes tied 
 behind the patient's neck. This 
 tube is provided with an inner can- 
 nula which is removed frequently 
 and cleansed, without disturbing 
 the outer tube. As k)ng as the tube 
 remains in pkace, the patient should 
 be kept in a moist warm atmos- 
 phere; this is best secured by em- 
 ploying a croup tent, and by the 
 use of a kettle of hot water, on the 
 surface of which is floated a small 
 quantity of compound tincture of 
 benzoin. It is an advantage to have 
 the outer tracheotomy tube con- 
 structed with a window on its convex surface, so that w^hen the inner 
 tube is withdrawn, tests can be made from day to day of the possibility 
 of laryngeal respiration. In emergencies, where a tracheotomy tube is 
 not available, one may be constructed out of a soft catheter or rubber 
 drainage tube. It rarely is possible to remove the tube permanently 
 before the third or fourth dav. In cases of stenosis from cicatrix or 
 
 Fig. 710. — Sagittal section of neck, 
 showing anatomical landmarks involved 
 in operations on the larynx and trachea. 
 
 Fig. 711. — Elsberg's three-bladed 
 tracheal dilator. 
 
 Fig. 712. — Tracheotomj- tube. 
 
 neoplasm it may be necessary to wear a tracheal cannula permanently. 
 In these cases a tube with a ball valve, permitting inspiration but 
 preventing expiration through the tube, may enable the patient to 
 employ his larynx in speaking. 
 
672 SURGERY OF THE FACE, MOUTH, AXD NJECK 
 
 Thyrotomy or Laryngo-fissure consists in splitting the thyroid car- 
 tihige in the mid-Hne, turning aside the halves, and exposing the 
 interior of the larynx. It is used to remove sessile benign growths, 
 and as an ex])loratory operation in cases not certainly malignant. 
 When malignancy exists the exploration should be followed imme- 
 diately by laryngectomy. 
 
 Laryngectomy may be partial {Heniilaryngectoiiiy) or complete {Extir- 
 pation of the Larynx). In the latter operation Hartley, of New York, 
 employs (1908) a cross-bow incision, analogous to that used in opera- 
 tions on the cerebullum. The transverse incision passes just below 
 the level of the hyoid bone, and the longitudinal extends far enough 
 downward to expose the isthums of the thyroid gland. The platysma, 
 sterno-hyoid and omo-hyoid muscles are turned down in the triangular 
 flaps. All superficial veins and both superior thyroid arteries are 
 ligated, the latter close to their origin; and the superior laryngeal 
 nerves are cut, after application of cocain to block inhibitory impulses. 
 The trachea then is cut away from the cricoid, is turned forward, and 
 is sutured end-on into the lower angle of the incision. Division 
 of the thyroid isthmus and free separation of the trachea from 
 the esophagus may be necessary. A tracheotomy tube is then intro- 
 duced, and the anesthetic subsequently administered by this route. 
 The sternothyroid muscles are then divided below the larynx. The 
 pre-laryngeal and lateral laryngeal lymph nodes are then raised, 
 together with the larynx and attached sterno-thyroid muscles, and the 
 pharynx is incised transversely behind the larynx, and the larynx, 
 including the epiglottis, is removed. All bleeding having been con- 
 trolled, the pharynx is completely closed by sutures (over a stomach 
 tube, passed through the nose, and used as a guide) ;^ the musculo- 
 cutaneous flaps are replaced and sutured, and the wound is drained 
 from one or both lateral angles. After-treatment is conducted as in 
 cases of tracheotomy. The patient should lie in the head-low position, 
 and should not swallow anything for three days. Until then he may 
 be fed liquids through the tube passed by the nose into the esophagus 
 at the time of operation. Crile (1913) points out that the chance 
 of infection may be lessened by a preliminary operation in which the 
 suprasternal space is widely opened on both sides of the trachea and is 
 packed with gauze. After several days when the wound is covered with 
 firm granulations, the surgeon proceeds to extirpation of the larynx. 
 
 The mortality of the operation is about 20 per cent. Nearly 50 
 per cent, of those who recover remain free of recurrence for one year 
 or longer. About 20 per cent, of those who recover are permanently 
 cured. Recurrence usually takes place, if at all. within one year. 
 If the deep cervical lymphatics are involved, no radical operation is of 
 any use. 
 
 Hemilaryngedomy is done by turning down a triangular flap on one 
 side only. A tube is inserted in the trachea well below the cricoid, 
 and after preliminary laryngo-fissure, the diseased half of the thyroid 
 cartilage is removed, with its related lymph nodes. 
 
 ^ This tube should be allowed to remain. 
 
SURGERY OF THE NECK 
 
 073 
 
 SURGERY OF THE NECK. 
 
 Wounds. Tlu'se niiiy he incised, lacerated, ^niiisliot, or stal) wounds. 
 The chief inunediate danj^'er is heniorrhaj^e or edema of the ^h)ttis. 
 Injuries of nerves, if undetected and not repaired, may lead to lasting 
 disahility. In suicidal cut-thront, the patient often loses his courage 
 when hlood hegins to flow, and the damage may not be nearly so great 
 as appears at first sight. If the trachea, larynx, or {)liarynx are 
 wounded, it frequently is safer to insert a tracheotomy tube at once, 
 to prevent asphyxia should edema of the glottis occur. Usually no 
 anesthetic is necessary. Hemorrhage should be controlled by expos- 
 ing, clami)ing, and ligating the l)leeding i)oints. ^'enous bleeding may 
 cease after respiratory obstruction 
 has been relieved by tracheotomy. 
 The superior laryngeal and the 
 h\l)oglossal nerves are those most 
 frecpiently severed in suicidal at- 
 tem})ts. No prolonged attempts 
 should be made to repair the nerve 
 injury unless the patient's condi- 
 tion is favorable. A lodged bullet 
 need not be removed unless ^■ery 
 easily accessible. Severed muscles 
 should be sutured. The wound 
 should be drained freely, as it is 
 in a region very prone to infec- 
 tion. 
 
 Woody or Ligneous Phlegmon 
 of the Neck (Reclus,. 1893;.— This 
 is a slow and indolent inflamma- 
 tion, j)robably due to attenuated 
 bacterial infection, the portal of 
 entrance of the infection being ini- 
 certpin. The inflammatory pro- 
 cess is said usually to begin below 
 the jaw in the submaxillary or 
 submental region, and extends to 
 the clavicle, usually on one side 
 only. It converts the normally 
 supple neck into a dense board- 
 like structure, neither painful nor 
 tender, and not attended by 
 noticeable constitutional reac- 
 tion. There may be an erythematous blush in the skin, and pos- 
 sibly some pitting on very firm pressure, but there is no evidence 
 of suppuration. The affection, which seems to be a cellulitis, begins 
 insidiouslv and ma^' last for weeks before medical attention is sought 
 (Fig. 713). 
 43 
 
 Fig. 713. — Woody or ligneous phlegmon 
 of neck. Struck by steel two months ago. 
 Slow, painless onset of induration, which 
 extends from mandible nearly to clavicle, 
 and from larynx to anterior border of 
 trapezius. Skin red, slight edema, and 
 pitting on pressure. No tenderness. 
 Poulticed for three daj's, then incised. 
 Rapid recovery. Episcopal Hospital. 
 
674 
 
 SURGERY OF THE FACE, MOUTH, AND XECK 
 
 Treatment. — The hoard-like area should he incised in several places, 
 and the neck should be poulticed. After suppuration is established, 
 the indurated tissues quickly soften, and recovery usually is unevent- 
 ful. This disease must not be confused with actinomycosis; the chief 
 point of resemblance is the board-like induration. 
 
 Lymphadenitis. — Inflammation of the lymph nodes probably occurs 
 oftener in the neck than in any other portion of the body. The 
 cavities of the nose, mouth, and pharynx constantly breed hordes 
 of microbes, and whenever the virulence of these is increased, or the 
 resistance of the patient lowered, they or their toxins are absorbed, 
 largely through carious teeth or the tonsils, and secondary enlarge- 
 ment of the cervical lymph nodes follows. The scalp also is a very 
 prolific source of infection for the cervical lymph nodes. Every year 
 I see a number of patients with cervical adenitis due to the infection 
 instituted by head lice. 
 
 It is of the utmost importance not to regard the lymphadenitis as 
 the main feature of the disease. The focus of infection always should 
 be looked for, and usually can be found if the examination is thorough. 
 If it is found and properly cared for, the lymphadenitis may subside 
 spontaneously. Examine the scalp, ear, teeth, lips, tonsils, nose, and 
 
 naso-pharynx, and do not be 
 satisfied until some source of 
 infection has been discovered. 
 The anatomical connections of 
 the various groups of cervical 
 lymph nodes should be re- 
 membered. Around the upper 
 part of the neck, as a collar, 
 are arranged, from before 
 backward, the submental, sub- 
 maxillary, subparotid, post-auri- 
 cular and occipital lymph nodes, 
 draining corresponding areas of 
 the face and head. The sub- 
 maxillary nodes receive the 
 drainage from all of the other 
 groups mentioned except the 
 occipital, and sometimes the 
 submental ; and all these groups 
 directly, or indirectly through 
 the submaxilhry, drain into the 
 upper portion of the deep cer- 
 vical lymph nodes, which form a chain along the internal jugular vein 
 from mastoid nearly to clavicle. These deep cervical lymph nodes 
 sometimes are infected directly from the primary focus of the teeth, 
 tonsils, scalp, etc., without implication of the intermediary group, 
 but in most cases the latter is infected first. The deep cervical 
 lymph nodes are also connected with the supraclavicular lymph nodes, 
 
 Fig. 714. — Tuberculous cervical and axillary 
 adenitis, in a girl of fifteen 5-ears; duration 
 nearly one year. Has had two operations on 
 neck, both probably incomplete; last, one year 
 ago. Episcopal Hospital. 
 
Slh'<;l':iiY OF THE \ECK 
 
 G75 
 
 which (iraiu the surfaces of the upper arm and axilhi, and sumetimes 
 the <)ccij)ital i)()rti()n of tlie scalj) and the inaniiuary ^hind. 'J'hese 
 sui)racla\icuhir 1\ nii)h nodes may l)e infected tlirough tlie deej) cervical 
 lymph nodes, or may in turn infect tliem. The deep cervical and 
 supracla\icular nodes are tliemselves drained into the subclavian vein 
 at its junction with tlie internal jufjular. The deej) l\inj)h nodes 
 ()f the neck lie beneath the sternomastoid muscle, and u])on the fascia 
 which covers the prevertebral muscles (scaleni, levator anguli scapulae, 
 etc.); their efferent vessels do not pass into the mediastinal nodes, 
 but occasionally they receive afferent lym})hatics from this source. 
 Occasionally the axillary lymph nodes become involved by infections 
 tra\ellin<; down the neck and through the supracla\'icular nodes 
 (Fig. 714). 
 
 Acute Lymphadenitis. — The affected nodes are swollen, tender, palpa- 
 ble, and sometimes visible as a diffuse swelling (Fig. 715). The more 
 acute the process the less distinctly can the individual node be out- 
 lined, and in many cases the affection is so acute that suppuration 
 has occurred before the surgeon is consulted. In the earlier stages, 
 attention to the focus of infection, 
 and application of ichthyol, bella- 
 donna and mercury, or compound 
 iodin ointment to the side of the 
 neck affected usually cause sub- 
 sidence of acute symptoms, and 
 the nodes cease to be palpable. 
 
 Fig. 715. — Acute submental lymph- 
 adenitis. Children's Hospital. 
 
 Fig. 716. — Submaxillary abscess from 
 acute lymphadenitis (not tuberculous), 
 due to carious teeth. Age eleven years. 
 Two months later other abscesses formed, 
 were incised and curetted. One year 
 later, formal operation for tuberculous 
 lymph nodes, evidently secondary to 
 previous inflammation. (See Fig. 36.) 
 Episcopal Hospital. 
 
 Abscess from cervical lymphadenitis (Fig, 716) requires the same 
 treatment as an abscess elsewhere; but as in many cases the abscess is 
 quite deeply seated, it often is best to open it by Hilton's Method; a 
 small superficial incision is made in the skin, under local anesthesia if 
 necessary, and then a grooved director is cautiously insinuated through 
 
676 
 
 SURGERY OF THE FACE, MOUril, AND NECK 
 
 the intervening structures until pus begins to flow; a pair of dressing 
 forceps is then passed along the grooved director, with its blades 
 closed; when it has entered the abscess cavity the blades are opened, 
 and the forceps is withdrawn, thus dilating the tract previously made. 
 In this way there is no danger of injuring important bloodvessels or 
 nerves. 
 
 Chronic Lymphadenitis. — Chronic lymphadenitis usually follows re- 
 peated acute attacks, the nodes retaining some inflammatory hyper- 
 plasia after each new infection. In the vast majority of cases, under 
 these circumstances, the nodes become secondarily infected with 
 tubercle bacilli. It is possible, of course, that the primary infection 
 may have been tuberculous, since even in cases which clinically are 
 thought not to be tuberculous microscopical study nearly always 
 reveals the characteristic lesions of tuberculosis; and in some cases 
 where no histological indication of tuberculosis was found, inoculation 
 experiments have been positive. 
 
 Fig. 717. — Tuberculous cervical adenitis 
 (submaxillary and subparotid). Duration six 
 months. Xo softening yet. Children's 
 Hospital. 
 
 Fig. 718. — Tuberculous cervical 
 adenitis. Age twenty-five years; 
 duration three years, no sinus. 
 From carious teeth. Orthopaedic 
 Hospital. 
 
 Tuberculous Lymphadenitis. — Tuberculous lymphadenitis in the neck 
 is an exceedingly common affection. For anatomical reasons, the 
 subparotid and submaxillary lymph nodes, draining the tonsils, teeth, 
 and anterior portions of the scalp, are those most often primarily 
 involved (Fig. 717) . Thence the disease spreads to the upper deep cer- 
 vical lymph nodes, travels along those accompanying the internal jugu- 
 lar vein to the clavicle, and often invades the supraclavicular group. 
 Tuberculous cervical adenitis occurs oftenest in those from fifteen to 
 twenty years of age, and is commoner in those under fifteen than in 
 
SlJRCEIiY OF Till-: M'U'K 077 
 
 tliosc ]);ist t\V(Mity-fi\(' years ol" aj^c. It may allVct one or hotli sides of 
 the iieek. I'sually, as noted ahoxe, there have heeii one or more attacks 
 of acute adenitis — seldom so acute as to lead to sui)})uration, and often 
 so subacute as to have recpiired no medical attention, the child l)einf^ 
 "doctored" at home with ham fat or ^oose fijrease. Such attacks often 
 date from the ])eri()(l of con\alescence foilowinjr measles or other acute 
 exanthem. Finally the nodes become so conspicucms, or so constantly 
 tender, even if invisible to a casual glance, that medical attention is 
 sought. The nodes are now more or less discrete, movable, elastic, but 
 tender; they do not feel hot, and give no evidence of fluctuation. They 
 vary from pea-size to that of a walnut, seldom larger. Almtjst always 
 there are a great many more present than can be detected by clinical 
 examination. When the affection is of still longer duration the sur- 
 geon finds, instead of discrete, elastic, and movable nodes, that there 
 are ill-defined, more or less immovable masses, evidently composed 
 of several coalesced nodes (Fig. 718) ; in one or two places there may 
 be evidence of softening. At a still later stage, cold abscesses form, 
 spontaneous fistulization may occur, and the neck is riddled with 
 sinuses, each separate and distinct node as it softens discharging 
 through a new orifice (see Fig. 36). If secondary pyogenic infection 
 occurs, a hectic state may develop. 
 
 The diagnosis must be made from Hodgkin's disease and from 
 malignant or syphilitic enlargements. A differential diagnosis from 
 chronic non-tuherculous inflammation usually is impossible, at least 
 in the early stages of tuberculosis, except from the results of treat- 
 ment, or by laboratory examination of an excised specimen. If cure 
 of the infecting focus and non-operative care of the neck causes nodes 
 to become no longer palpable, it may be assumed that the condition 
 was not tuberculous, or only very slightly so. Hodgkins disease 
 usually is easily recognized by the firmness of the nodes, their tendency 
 to enlarge without coalescing or softening, and by involvement of 
 other groups of lymph nodes as well as the cervical. Carcinoma is 
 secondary to a growth elsewhere, though this growth may have been 
 excised many years previously, and there may be no local recurrence 
 and an inconspicuous scar. Such lymph nodes are hard and not tender, 
 and the patients are very rarely indeed of an age when tuberculous 
 adenitis is frequent. Sarcoma of the cervical lymph nodes is rare. 
 In its early stages it resembles clinically a case of Hodgkin's disease, 
 but affects only the cervical lymph nodes; it never suppurates, but 
 tends to involve the skin, and to form a fungous ulcer. It is important 
 to recognize the existence of syphilis, particularly the hereditary form, 
 in cases of the cervical l\Tnpli nodes. It occurs about puberty, and 
 its syphilitic nature should be suspected from the presence of other 
 signs of the disease (Fig. 938). 
 
 Prognosis and Treatment. — The prognosis of tuberculous cervical 
 adenitis is bad, unless it is properly treated. Not only does the local 
 condition go from bad to worse, but the patient's general health 
 steadily deteriorates. Statistics collected in 1905 by Dowd, and so 
 
678 
 
 SURGERY OF THE FACE, MOUriL AXD NECK 
 
 far as I know not since contradicted, showed that without operation, 
 but with medical treatment only, from 21 to 25 per cent, of these 
 patients ultimately develop phthisis. This is small wonder, when 
 the drainage of the cervical lymph nodes into the right heart is remem- 
 bered. In 1909 Dowd traced ninety-six patients on whom he had 
 operated more than three years previously. He found nearly 94 per 
 cent, apparently cured; one death; and five patients with recurrence 
 which could be cured by operation. Xo other form of treatment gives 
 such satisfactory results. Even in children, in' whom temporizing and 
 medical methods often are regarded as more legitimate in this affection 
 than in adults, the prognosis is better if the diseased h'mph nodes are 
 removed by operation. But in every case the source of injection must 
 he cured. Xo matter how thorough the operation, if the infecting focus 
 
 Fig. 719. — ■ Tuberculous cervical 
 Ij-mph nodes; duration six months, 
 following measles. (See Figs. 719, 
 720, and 721.) Children's Hospital. 
 
 Fig. 720. — Same patient as Fig. 719, 
 after operation, showing temporary para- 
 lysis of depressor anguli oris. (See also 
 Figs. 721 and 722.) Children's Hospital. 
 
 remains in scalp, tonsil, pharynx, or elsewhere, other nodes not detected 
 at the first operation will become diseased, and the patient will be no 
 better off than before the first operation. If there are chronically 
 enlarged lymph nodes in the neck, the first thing, to do is to cure the 
 source of infection ; the lymph nodes may then cease to give symptoms. 
 If they do not, they almost certainly are tuberculous, and should be 
 removed. Occasionally the lymphatic invasion is so much more 
 disabling than the source from which the infection is derived, that it 
 is justifiable to do the operation on the cervical lymphatics first, 
 and to postpone cure of the nasal or tonsillar or dental or scalp con- 
 dition, until comparative health has been restored; but in many such 
 cases a recurrence in the neck will take place because the infecting 
 focus is too long neglected. Seldom or never is it advisable to under- 
 take a nose or throat operation at the same time that the neck opera- 
 
SL'RiJERY OF THE SECK 
 
 079 
 
 tion is done. If there are adenoids, enlarj^ed tonsils, etc., it is better 
 to attend to them one or two weeks before tiie neek operation is done; 
 and a week or ten days nsually should ehipse between oj)erations if 
 both sides of the neek are involved. The neck operation frequently 
 is one of great difficulty, and if properly done always is tedious and 
 lengthy (Figs. 719, 720, 721 , and 722). 
 
 Fig. 721. 
 
 -Same patient as Fig. 719, sliuwiiit? Dowel's incision for cervical 
 adenitis. Children's Hospital. 
 
 Operation. — If the nodes only in the upper portion of the neck are 
 involved, they may be reached conveniently through Dowd's upper 
 incision, which runs in the direction of the folds of the neck an inch or 
 more below the jaw (Fig. 721). Cut through the platysma and deep 
 
 Fig. 722. — Mass of tuberculous lymph nodes removed entire, showing groove for 
 great vessels (three-fourths natural size). (See Figs. 719, 720, and 721.) Children's 
 Hospital. 
 
 fascia before reflecting the margins of the wound, so as to avoid injury 
 to the branch of the facial nerve which supplies the depressor labii 
 inferioris; this nerve runs between the deep fascia and platysma, about 
 a finger's breadth below the mandible, and is the only branch of the 
 
680 
 
 SURGERY OF THE FACE, MOUTH. AND XECK 
 
 facial nerve exposed to injury (Fig. 720). Then identify the anterior 
 border of the sterno-mastoid muscle, and work under its margin until 
 the carotid sheath is exposed below the enlarged lymph nodes. These 
 should then be removed by careful dissection (not blunt tearing) from 
 below upward, in one mass (Fig. 722). The chief dangers are hemor- 
 rhage from large branches of the internal jugular vein, especially the 
 facial and temporo-maxillary veins; and injury to important nerves, 
 notably the hypoglossal and spinal accessory. 
 
 If the lower deep cervical lymph nodes are involved, a second trans- 
 verse incision, parallel to the first, and several inches lower, may be 
 added. These nodes are most easily exposed along the posterior border 
 of the sterno-mastoid muscle. As one works along this from below 
 upward, the first nerves encountered are branches of the superficial 
 cervical plexus, emerging about the middle of the posterior border of 
 the sterno-mastoid; and about an inch higher up the spinal accessor}' 
 
 is encounteredf as it leaves this 
 muscle and crosses the posterior 
 cervical triangle to the trapezius 
 muscle. The sensory nerves may 
 be sacrificed, but the spinal acces- 
 sory should be preserved. 
 
 In cases where there is very exten- 
 sive involvement, including the 
 supraclavicular nodes, and where 
 the tissues are densely adherent, 
 it is better to turn down a large 
 triangular flap, as indicated in 
 Fig. 723. This flap is turned 
 downward and forward, the pos- 
 terior incision being extended for- 
 ward above the clavicle if neces- 
 sary. The dissection is begun at 
 the clavicle and proceeds upward, 
 the diseased tissue being removed 
 in one mass. If the surgeon can 
 once lay bare the prevertebral muscles he will be able to remove 
 the entire lymphatic area of the neck. In exceptional cases trans- 
 verse division of the sternomastoid muscle may be necessary. The 
 existence of a cold abscess or even of a sinus, if uninfected, does not 
 interfere with repair of the wound. 
 
 The wound should be closed with two layers of sutures, the first 
 to the platysma and fascia, and the second in the skin. Xeglect to 
 suture the platysma separately allows stretching even of a transverse 
 scar. Drainage should be provided for by small tube, for the first 
 few days; and after extensive operations the patient's head should be 
 immobilized by sand-bags until healing is well under way. 
 
 Tumors of the Carotid Body or Gland usually are clinically malig- 
 nant. Pathologically they are peritheliomas or endotheliomas. The 
 
 Fig. 723. — -Flap incision for cervical 
 adenitis four months after operation. 
 (Scars emphasized in reproduction.) 
 Episcopal Hospital. 
 
SURGERY OF THE NECK 
 
 OSl 
 
 timior occurs in youii",^ itdiilts, uiid is sl()\v-gr()\vill^^ jKiiiilcss, dense, 
 and noii-iiiflaminatory. Its clinical course extends throiigli many 
 years, hut sudden <,To\\tli may dcx'elop at anv time. Eventually 
 the growth surrounds and compresses the carotid arteries, and causes 
 symptoms from pressure, especially from pressure on the sympathetic, 
 hypoglossal, and vagus nerves. The dinqnosis is made chiefly by exclu- 
 sion. The tumor is situated at the bifurcation of the common carotid 
 artery, and receives transmitted pulsation; but this pulsation is not 
 expansile, and there is no thrill nor bruit. Compression of the com- 
 mon carotid artery does not affect the tumor. The absence of primary 
 growth elsewhere, the long duration, and the younger age of the 
 patient, exclude carcinoma. Sarcoma grows much more rai)idly, and 
 tends to soften and ulcerate. 
 
 Treatment. — If seen very early, extirj^ation may be undertaken; 
 but very soon the operation becomes one of the utmost difficulty and 
 great danger. The mortality thus far is about 25 per cent. Operation 
 usually involves ligation of the common carotid artery l>elow and of 
 the external and internal carotids above the growth, for it cannot be 
 separated from them safely. Other structures should be preserved if 
 possible. In one case it was necessary to remove part of the base of 
 the skull to secure the internal carotid above the growth; and irre- 
 parable damage has been done to both recurrent and superior laryn- 
 geal nerves, to the hypoglossal and even the facial nerve. If it appear 
 improbable that the operation can be completed, it should not be 
 attempted, or if begun, should be abandoned in good time. 
 
 Fig. 724. — Thyro-glossal cyst: at 
 birth size of walnut; steady growth 
 since. Age four years. Orthopaedic 
 Hospital. 
 
 Fig. 725. — Thyro-glossal cyst; age four 
 years. Orthopaedic Hospital. 
 
 Thyro-glossal Cysts and Fistulae.— The thyro-glossal duct in the 
 embryo runs from the foramen cecum of the tongue through or behind 
 the hyoid bone, in the mid-line of the neck, to the thyroid gland. If 
 the duct fails to be obliterated, any portion which remains may become 
 
6S2 
 
 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 dilated and form a cyst; and if the cyst ruptures externall\- a fistula 
 will result. These cysts and fistulae always are in the median line of 
 the neck. They may be above the hyoid bone, over it, below it, or 
 the entire thyro-glossal duct may be persistent. Usuallv these cysts 
 are noted in childhood (Figs. 724 and 725), but sometimes no trace of 
 them IS observed until puberty (Figs. 720 and 727). The cvst slowly 
 and painlessly increases in size, and relief is sought for deformitv or 
 pressure effects. A thyro-glossal fistula secretes a little mucoid matter; 
 pain may result from retention of its contents if the orifice becomes 
 scabbed. Suprahyoid cysts are lined by stratified squamous epithe- 
 lium; those arising lower in the thyro-glossal tract are lined bv 
 columnar (sometimes cilated) epithelium. 
 
 Fig. 726. — Thj-ro-glossal cyst, age 
 fourteen years; duration one year. 
 Episcopal Hospital. 
 
 Fig. 727. — Thyro-glossal cj'st. Same patient 
 as Fig. 726. Episcopal Hospital. 
 
 Treatment. — Extirpation should be done, removing carefully every 
 trace of the duct wall. Recurrence will take place if any portion 
 remains. The dissection is difficult and should not be undertaken 
 by an unskilled operator. 
 
 Branchial Cysts and Fistulae.— These result from maldevelopment 
 of the branchial arches and clefts of embryonic life. They are situated 
 laterally in the neck, and thus are easily distinguished from the median 
 thyro-glossal remains. Branchial fistulae usually open along the anterior 
 border of the sterno-mastoid muscle, and may extend as far as or 
 even into the pharynx. The condition is congenital, but the patient 
 may not seek relief until adult life, and the cysts may be of insignifi- 
 cant size until the occurrence of some injury (Fig. 728). If the cyst 
 lies near the pharynx it will have lymphoid tissue in its walls. 
 
SURGERY OF THE NECK 
 
 ()S8 
 
 Treatment. Extirpation, which is the only successful treatment, 
 invoK cs a verv much more delicate dissection than that ot the median 
 evsts already" mentioned; and even skilled dissectors may have to 
 repeat the o'peration a numl.er of times. Disten.lmK the sinus with 
 parafhn. wliich is injected hot and allowed to hanlen ni .<^itii, is a 
 
 ''Branchiogenic Carcinoma (Langenbeck, 1861; Volkrnann 1882) - 
 Occasionallv a carc-iiu.ma .levelops in a branchial cleft Diagnosis 
 before operation is difhcult. It may resemble a tumor of the carotid 
 bodv, but occurs in older persons, its duration is measured by ^yeeks 
 or months, not bv vears, and it is adherent to the skin. Treatment 
 involves extirpation of the tumor with the overlying skin. 
 
 Fig. 72S. — Branchial cyst of neck; age 
 eighteen vears; duration seven months; 
 followed a fall. Orthopaedic Hospital. 
 
 YiQ 729. — Cystic fibroma of cheek 
 and neck; twenty-five years' duration. 
 Weight of tumor three pounds and tive 
 ounces. Excised by the late Prof. 
 Ashhurst, 1896. University Hospital. 
 
 Hygroma.-This is an old clinical term used to describe cervical 
 evsts of diflerent nature. The subject has been studied recently by 
 Dowd (1913). Some are lymphangeiomatous m character: these are 
 congenital, usually occupy the posterior triangle, seldom cause dis- 
 abilitv, often grow smaller and may even disappear as the patients 
 grow older. Their removal is difficult and dangerous, and should not 
 be attempted unless pressure symptoms render relief imperative. 
 Often the most that can be done is to excise the anterior and parts 
 of the lateral walls of the cyst, and pack its cavity with gauze^ looking 
 for a cure bv granulation, cicatrization, and contraction. Occasion- 
 allv the cvst extends into the axilla. Hemorrhagic cysts may result 
 from traumatic or spontaneous hemorrhage into ^ p^xisting cyst 
 Bursal cysts, occurring in preexisting bursse around the hyoid bone 
 or thyroid cartilage, result from effusion due to trauma or constitu- 
 tional disease. 
 
684 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 Lipoma is freciueiit in the neck. Fibroma is ratlicr unusual; it gen- 
 erally springs from the deep fascia, is slow growing; may in time 
 undergo degenerative changes (Fig. 729), and reaches an immense size. 
 
 SURGERY OF THE THYROID GLAND. 
 
 Inflammation. — Inflammation of the normal thyroid gland is com- 
 paratively rare. It is described as thyroiditis, and must be distin- 
 guished from strumitis, or inflammation of a goitrous gland (p. 688). 
 Acute thyroiditis, seldom leading to abscess, occurs by infection 
 through the blood-stream in general infections such as typhoid fever, 
 scarlatina, etc. The entire gland is enlarged and tender, and pressure 
 symptoms are usual. If suppuration is suspected an incision should 
 be made. If multiple abscesses exist, or if necrosis occurs, partial 
 excision should be done. Chronic thyroiditis is much less unusual than 
 the acute, and usually is chronic from the start, seldom following an 
 acute attack. It occurs usually in alcoholic or arteriosclerotic adults, 
 and may be caused by syphilis (gummatous form), tuberculosis, or 
 prolonged use of iodin. Operation may be required for diagnosis 
 in cases of asymmetrical involvement of the gland, or to relieve pres- 
 sure. Ligneous or woody thyroiditis (Riedel, 1896) is believed by Delore 
 and Alamartine (1911) at times to be one of the manifestations of 
 what Poncet calls inflammatory tuberculosis. Clinically the diagnosis 
 from carcinoma is difficult, and pathologists interpret the histological 
 pictures differently. Compression of the trachea is frequent, and 
 demands intervention. This should consist merely in resection of the 
 thyroid isthmus. Radical operation is nearly impossible and is not 
 necessary. The use of the .r-ray may hasten regression of the disease. 
 
 Goitre. — This is a clinical term used to describe an enlargement 
 of the thyroid gland. It is derived from the Latin word for throat 
 (guttur). The thyroid is an epithelial gland which in embryonic life 
 had a duct, the thyroglossal duct. The presence or absence of a goitre, 
 and the existence or non-existence of constitutional symptoms in con- 
 nection with it, depend on the inter-relation of secretion and absorp- 
 tion in the thyroid gland. In fetal life there is little or no evidence of 
 secretion. At puberty the thyroid becomes more active, and, as noted 
 below, sometimes enlarges. In adult life whatever secretion is pro- 
 duced is normally absorbed by the body tissues. In abnormal states 
 there is excess of secretion, and this is either not so absorbed, and 
 accumulates in the thyroid ("cystic" goitre); or else is absorbed and 
 produces toxemia (hyperthyroidism). Whenever hyperthyroidism 
 exists there is an increase in the secreting surface of the thyroid; 
 this results either in a parenchymatous hypertrophy (without cyst 
 formation), or in intra cystic papillomatous out-gro^i:hs (if the change 
 occurs in a thyroid previously cystic). When instead of paren- 
 chymatous hypertrophy, there is marked increase in the interglandular 
 connective tissue, the amount of secreting surface is relatively 
 decreased; this is the case in the thyroids of cretins (hypothyroidism) 
 
SURGERY OF THE THYROID GLAND 
 
 ()S5 
 
 and tlic ttTin hyptTtropliic fetal thyroid is ai^jjlicd. 11' in a fetal type 
 of thyroid the epithelial (secreting) elements are in excess, we have 
 an adenomatous thyroid, and symi)t()ms of hyperthyroidism ma\' or 
 may not he present. Patients in whom atrophy of secreting cells has 
 occurred, usually as the result of pressure from accumulated and not 
 absorbed secretion (chiefly, therefore, in cases of cystic thyroid), are 
 those who are spontaneously cured of their toxic symptoms; in some 
 such cases the final state may be one of hypothyroidism (jMacC"art\', 
 1910). 
 
 Physiological enlargement of the thyroid gland often occurs in girls 
 at puberty (Fig. 730),, the enlargement persisting for a year or more 
 and then gradually subsiding. 
 Sometimes enlargement recurs at 
 every menstrual period or during 
 pregnancy; and occasionally the 
 enlargement which appeared at 
 puberty never subsides. The 
 gland is uniformly and symmetric- 
 ally enlarged. No symptoms are 
 present and the patient may not 
 be aware of the existence of a goitre. 
 Xo treatment is required. 
 
 Pathological enlargement of the 
 thyroid gland is endemic in certain 
 regions, notably in Switzerland; it 
 is frequent in French Canada, and 
 in some other parts of North 
 America. It is generally believed 
 that this enlargement is associated 
 in some way with the drinking 
 water of the patients; and it seems 
 probable that the cause is some 
 qualitative change in the iodin 
 constituents of the drinking water. 
 
 The enlargement may be diffuse or circumscribed ("jiodular"). This 
 classification of Kocher is in general use, and is very convenient for 
 purposes of clinical study. 
 
 Diffuse enlargement involves both lateral lobes and isthmus pro- 
 portionately. It usually is due to more or less uniform increase in 
 all the elements of the thyroid {follicular and parenchymatous goitre) 
 or to disproportionate increase in the colloid material {colloid goitre). 
 In the latter and more frequent form, the consistency of the swelling 
 is harder, and the individual lobules appear larger and are more 
 easily defined. A diffuse rascular goitre is one of any form in which 
 vascularity is marked. A diffuse fibrous goitre is the result of inflam- 
 mation and cicatricial changes in any of the forms mentioned, and is 
 very rare. There is also a form of diffuse adenomatous goitre which 
 it is better to classify among malignant growths. 
 
 _ Fig. 730. — Pli\-.-ioli.Lri(;al goitre, in a 
 girl of thirteen j-ears. Orthopaedic 
 Hospital. 
 
686 
 
 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 Circumscribed or nodular enlargement may occur in any of the prin- 
 cipal forms already mentioned: follicular, colloid, or adenomatous. 
 The colloid or " cystic" goitre is by far the most frequent form. Nodu- 
 lar goitre is characterized (1) by the irregularity and inequality of 
 the enlargements; and (2) by their tendency to undergo degenerative 
 changes, such as colloid, hyaline, calcareous, etc., and to intracystic 
 hemorrhages. Single nodules are most common in one of the lower 
 poles of the lateral lobes; occasionally they occur in one of the upper 
 poles; and very rarely in the isthmus or in the pyriform lobe when 
 the latter is present. Multiple nodules may exist. As the nodules 
 increase in size they displace the remaining normal gland structure, 
 and may become more or less encapsulated. Occasionally a diffuse 
 colloid goitre is converted into a goitre with multiple cystic nodules; 
 these have little tendency toward degeneration or internal hemor- 
 rhages. 
 
 Symptoms and Diagnosis. — Diffuse goitre retains the shape of the 
 normal gland, and rarely attains very large size. The tumor, as in 
 all thyroid affections, rises with the larynx in the act of swallowing and 
 in coughing. It is movable laterally, but scarcely at all up and down. 
 Pressure symptoms are rare. Sometimes venous engorgement is visible 
 over the root of the neck or upper thorax. In nodular goitre the relation 
 of the swelling to the thyroid is determined by its location in the neck 
 
 over the normal site of the thyroid, 
 and by its movement with the larynx 
 in deep breathing, sw^allowing, and 
 coughing. The swelling is close to 
 the median line of the neck, but 
 usually is distinctl,y lateral in its at- 
 tachment. As it increases in size it 
 may become pendulous (Fig. 731). It 
 pushes forward the sub-hyoid muscles, 
 and displaces the sterno - mastoid 
 muscle and great ^'essels of the neck 
 laterally, so that the vessels may be 
 palpable at the posterior border of 
 this muscle; it may distort or com- 
 press the trachea and esophagus; and 
 may cause symptoms from pressure 
 on the sympathetic, recurrent, or 
 superior laryngeal nerves. Rarely a 
 goitre may grow down behind the ster- 
 num, when its presence may be detected by percussion. Finally, a goitre 
 may produce disturbance of the heart and circulation, either directly 
 by pressure on the great vessels, or through interference with respira- 
 tion; or in some instances from hyperthyroidism (p. 688). Intermit- 
 tent pressure on the great vessels of the neck may produce giddiness 
 and other evidences of disturbances in the intracranial circulation. 
 In diffuse follicular and in imrenchymatous goitres the diagnosis 
 
 Fig. 731. — Cystic goitre, of sixteen 
 years' duration in a patient of thirty- 
 seven years. Pennsylvania Hospital. 
 
SURGERY OF THE THYROU) dLANI) ()S7 
 
 rests on the soft, flabby consistency, palpation of the small but rather 
 distinct lobules, and the vascularity. Early symptoms of hyper- 
 thyroidism may be i)resent, and these usually will be increased by the 
 administration of iodin. The (liffu,sc roUoUl goitre is relatively firm, 
 the lobules are much larger, and some are quite hard; iodin causes no 
 diminution in size. The dif use fibrous goitre is harder, and there are 
 symptoms of hypothyroidism. 
 
 In nodular colloid goitre (cystic goitre) the diagnosis often is made at 
 a glance. The surface of the cyst is smooth, its form is oval or rounded, 
 and its consistency elastic. The adenomatous goitre is recognized by 
 its circumscribed character, and its soft and doughy feel. 
 
 Treatment.— In many cases of difi"use goitre, judicious medical treat- 
 ment, with attention to hygiene, will cause diminution or complete 
 subsidence of the swelling. Operation is required only for cosmetic 
 efl'ect, to relieve pressure symptoms, or to check progressive growth 
 or a tendency toward hyperthyroidism. In most cases of nodular 
 goitre operation is indicated at an early stage, for the same reasons 
 which render its adoption advisable at a later stage in the diffuse form. 
 This is particularly true of nodules undergoing degenerative changes, 
 and especially of the nodular adenomatous form, since in this the ten- 
 dency to malignant change is well marked. Finally, it may be stated 
 in general terms, that any goitre of rapid growth or tender on pressure 
 should be referred to the surgeon. 
 
 The operation consists in excision of the affected lobe; or in case of 
 one or two large nodules, in their enucleation; as the nodules usually 
 are fairly well encapsulated the remainder of the gland may be left 
 intact, to prevent development of symptoms of hypothyroidism. 
 Enucleation is indicated especially where it is probable that very 
 little healthy functionating gland tissue remains. In diffuse goitre 
 it usually is found sufficient to excise one lobe, with a part of the isth- 
 mus; the remaining lobe may then cease to cause symptoms. Should 
 these continue, a part or whole of the second lobe may be removed 
 subsequently. Kocher's incision is a transverse incision, slightly 
 convex downward, crossing the neck over the prominence of the 
 thyroid, from one sterno-mastoid muscle to the other. In operations 
 on one lobe only, the incision need be only half as long. The flaps, 
 including plat^'sma and fascia, are then dissected upward and down- 
 ward, exposing the pre-thyroid muscles. These may be divided near 
 the hyoid bone, if necessar>', thus preserving their nerve supply, and 
 the tumor may then be dislocated into the wound. In all thyroid- 
 ectomies, partial or complete, hemorrhage should be scrupulously 
 avoided, by clamping and ligating veins as they are encountered, 
 and securing the superior and inferior thyroid arteries of the affected 
 lobe before its excision is begun. Both arteries should be secured 
 close to, or after entry of their branches into the gland. This is 
 especially important in case of the inferior thyroid, so as to avoid 
 interference with the circulation of the inferior parathyroid glandule 
 (p. 691). Then the capsule of the gland is split open along its lateral 
 
688 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 aspect, and the lobe is removed, leaving part of it adherent to the 
 posterior portion of the capsule, so as to avoid injury to the parathy- 
 roid glandules and the recurrent laryngeal nerve. The occasional 
 presence of a thyroidea ima artery should be remembered. The 
 isthmus is clamped and is ligated, in the groove made by the clamp, 
 before it is divided. Severed muscles are then sutured, and the wound 
 is closed with ample drainage. 
 
 Strumitis. — Inflammation of a goitrous thyroid is less unusual .than 
 that of the normal gland. The diagnosis rarely is flifficult, and the 
 treatment is the same as for corresponding forms of thyroiditis. 
 
 Hypothyroidism. — In persons from whom the entire thyroid gland 
 is removed there usually develops a condition of acquired cretinism, 
 known as myxedema, or cachexia thyreopriva. The signs of this con- 
 dition need not be detailed here. A knowledge of the condition 
 is sufficient to warn the operator not to remove all the function- 
 ating thyroid tissue. If this course has to be pursued in the eradi- 
 cation of malignant disease, the patient should ingest daily a sufficient 
 quantity of thyroid extract to keep the myxedematous symptoms in 
 abeyance. Transplantation of thyroid tissue, from man and from some 
 lower animals, has been tried in such cases, and in some instances 
 with encouraging results. The portions of thyroid gland have been 
 implanted subcutaneously, in the subserous tissues, in the splenic 
 pulp, and in the bone marrow. In most cases, even if the graft 
 functionates properly for a time, it eventually is absorbed, and 
 myxedematous symptoms again develop. 
 
 Hyperthyroidism {Exophthalmic Goitre, Graves's Disease (1835), 
 Basedow's Disease (1840), Thyrotoxicosis). — Administration of thyroid 
 extract in excess to normal persons causes the development of certain 
 symptoms which are also present in some diseased states of the thyroid 
 gland. These symptoms are the direct antithesis of those observed 
 in myxedema. They may be grouped in four main categories: (1) 
 Local changes in the thyroid. (2) General circulatory symptoms. (3) 
 Nervous symptoms. (4) Metabolic changes. There should also be 
 mentioned exophthalmos, which usually is present, but sometimes is 
 not associated with other typical symptoms. 
 
 The affection is much commoner in women than in men (about 
 6 to 1), and occurs usually between the ages of fifteen years and thirty- 
 five years; it is less rare after thirty-five years than before puberty. 
 It appears to be induced by physical or mental exhaustion, worry, 
 anxiety, fright, fear, etc. Sometimes it develops very acutely; in 
 others very rapidly, but not suddenly; at other times its onset is 
 insidious. In the cases which develop rapidly, the goitre usually 
 makes its first appearance at the time that the thyrotoxic symptoms 
 develop; in the chronic cases, with slow onset, a goitre usually has 
 been present for months or years before hyperthyroidism ensues. 
 
 Local Changes. — The thyroid usually is enlarged symmetrically 
 and diffusely. Its vascularity is increased, giving it a soft feel; but 
 deep pressure detects a gland firmer than normal. Nodular goitre 
 
SURGERY OF THR THYUOUJ dLAND 
 
 ()89 
 
 rarely is associated with tli\ ro-toxie s\ iiiptoins. The more acute 
 the onset, the more marked are the local ehanj^es. In cases of long 
 duration, especially when medical treatment has heen prolonged, 
 the gland hecomcs smaller and firmer, hut tiie vascular phenomena 
 may be demonstrated again after excitement. In some cases no local 
 changes are ])ercej)til)le, and the diagnosis depends on other signs. 
 
 Circulatory Symptoms. — Tachycardia is the most prominent symp- 
 tom: the ])ulse is ahnormally frecjucnt, (piick, usually of high tension, 
 and extremely irritable (A. K'ocherj. These changes may he acute 
 in onset, or very gradually de\elop. Excitement always accentuates 
 them. 
 
 Nervous Symptoms. — Restlessness of mind and body is exceedingly 
 characteristic. The patient inclines to be hysterical, and weeps with- 
 out j)r()\ocation; there is insomnia; tremor, especially marked in the 
 hands, tongue, and lips; and various psychoses may develop. 
 
 Fig. 732. — -Exophthalmic goitre. Fig. 733. — Exophthalmic goitre. Same 
 
 Duration seven year-s; twenty-eight patient as Fig. 732. Episcopal Hospital, 
 
 years old. Has had seven children. 
 Goitre has grown rapidly during the 
 last year. No tachycardia or ner- 
 vousness. Exophthalmos not noticed 
 by patient. Episcopal Hospital. 
 
 Metabolism. — In general terms, all metabolic activity is increased. 
 The skin is warm and moist; the temperature slightly raised; the 
 amount of urine increased; weight is lost, and in advanced stages 
 emaciation may occur. Brown atrophy of the heart and degenerations 
 of the other viscera develop eventually, and render recovery impossible. 
 There is great weariness quite early in the disease. Frequent attacks 
 of diarrhea may occur. Capillary hemorrhages are not infrequent. 
 The blood-changes are said by Kocher to be characteristic, and almost 
 pathognomonic: there is slight leukopenia, but marked increase in 
 the actual and proportional number of lymphocytes, \vhich may out- 
 number the neutrophile leukocytes; the red blood cells and hemoglobin 
 remain unaltered. 
 44 
 
690 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 Exophthalmos is not a necessary feature of hyperthyroidism. It 
 may be present, and associated with a goitre, without any of the cir- 
 culatory, nervous, or metaboHc symptoms which are characteristic 
 of the disease (Fig. 732). Its pathogenesis is not understood. It may 
 be absent when other symptoms of the disease are very pronounced. 
 
 Diagnosis. — This depends on recognizing the circulatory, nervous, 
 and metabolic symptoms which have been detailed above; and on the 
 blood-changes, on which great stress is laid by Kocher. The existence 
 of a palpable goitre and exophthalmos are confirmatory signs, but by 
 no means necessary for a diagnosis. The histological diagnosis, as 
 pointed out at p. 684, depends on the recognition of increase in the 
 secreting surface of the gland, quite apart from other changes which 
 may be present. 
 
 Prognosis. — Theoretically, hyperthyroidism is a self-limited disease; 
 but the disease may kill the patient before it burns itself out. In 
 rare cases the thyrotoxic symptoms subside, perhaps aided by medical 
 treatment, and those of hypothyroidism succeed. The thyroid thus 
 may destroy itself by hypersecretion. But in most cases the disease 
 grows progressively worse. The more acute its onset, the more rapid 
 is its course. Acute exacerbations characterize some rather subacute 
 cases. In these and in the hyperacute cases, death may occur in a 
 paroxysm, with rapid cardiac exhaustion (delirium cordis), general 
 edema, albuminuria, fever, dyspnea, etc. In other, more chronic,^ 
 cases, death occurs from intercurrent maladies, such as influenza or 
 tonsillitis; it may occur merely from administration of an anesthetic 
 for operative purposes, since viscera damaged by the long continuance 
 of intoxication cannot functionate under these additional demands. 
 
 Treatment. — As the disease is due to intoxication from the thyroid 
 gland, there are two logical remedies: one is removal of part of the 
 gland, the other is the preparation and administration of an antitoxic 
 serum. The latter has been tried by Beebe and Rogers, but not with 
 the uniform success w^hich has attended operative treatment, and 
 must be continued indefinitely as the cause of the symptoms is not 
 removed. In the hyperacute cases usually no treatment is of use, 
 and death occurs in a short time. In the subacute cases, in which the 
 thyrotoxic symptoms and the goitre appear simultaneously, medical 
 treatment should be tried before resort to operation, as by procuring 
 absolute rest for mind and body it is possible to ameliorate the patient's 
 condition. In most cases confinement to bed is imperative, in isola- 
 tion. Local cold is of great value in quieting the tachycardia. Kocher 
 thinks iodin internally is of much value. The bowels and kidneys 
 must be looked to, and a milk diet may be beneficial. Belladonna or 
 atropin, with an occasional course of bromides, are useful in controlling 
 circulatory disturbances. If no improvement is evident within a 
 couple of weeks, it is useless to pursue this treatment further, and 
 operation should be undertaken, as it should even earlier if the patient 
 continues to grow worse, and in the more chronic cases where it may 
 be employed safely without such careful preparative treatment. 
 
SURGERY OF THE THYROID GLAND (391 
 
 The Parailit/rolds. — In all ()i)tTati()ns injury i)f the jjarathyroids 
 should be avoided; for thou<;;h Shepherd attaches little importance 
 to them, other surgeons of etpial or fjreater experience (Kocher, ('. 
 H. Mayo, Crile, Halsted) entertain the greatest respect for their 
 powers of good and evil. These little glands, of uncertain function, 
 usually are four or more in iuunl)er; they are situated two on each 
 side of the neck behind the thyroid gland, and separated from it by 
 the posterior ])ortion of its capsule. The lower pair are in relation 
 with the terminal branches of the inferior thyroid artery, and are 
 the more constant in position. The upj)er parathyroids are supplied 
 either from the superior thyroid artery or from communicating 
 branches from the inferior thyroid. Removal or destruction of all 
 the parathyroids is supposed to be the cause of post-operative tetany, 
 which has been seen in a few cases. As it is impossible to identify 
 the parathyroids except by histological examination (macroscopically 
 they cannot be distinguished from lymph nodes), the only safe course 
 is to keep clear of the site where they normally are found. This is 
 best done in excisions by leaving the posterior portion of the capsule 
 and, if necessary, a layer of thyroid tissue adherent to it. 
 
 Operation. — In severe cases it is the custom first to diminish the 
 thyrotoxic symptoms by ligating one or more of the arteries supplying 
 the gland; and to proceed to partial excision within a week or ten days, 
 before the favorable effect of the preliminary operation has passed 
 away. In very acute cases the patient will be so much worried and 
 excited by the anticipation of any operation, that Crile has adopted 
 the ingenious plan of instituting a course of very strict pre-operative 
 treatment, repeated every morning, and embodying the essential 
 steps in preparation for operation, as if they in themselves consti- 
 tuted the treatment. Every morning the patient's neck is washed as 
 if for operation, and dressings are applied; every morning she inhales 
 some essential oil, to simulate an anesthetic. Then some favorable 
 morning, in the course of usual routine, a real anesthetic is given, 
 and the operation is completed without the patient being aware of any 
 change from the daily routine. In Kocher's hands, the mortality of 
 operation in 200 severe cases was 4.5 per cent.; and there were S5 
 per cent, of cures. In cases with advanced visceral degenerations 
 operation is useless. 
 
 Ligation. — j\Iost surgeons follow Kocher in ligating one or both 
 superior thyroid arteries. But Delore and Alamartine (1911) have 
 pointed out that the circulation is much better controlled if the 
 superior and inferior thyroids on the same side are ligated. Halsted 
 (1913) now ligates both inferior thyroids. The sujjerior thyroid artery 
 is exposed by a small transverse incision over the upper pole of the 
 lateral lobe, which usually is palpable through the skin; the sterno- 
 mastoid is drawn backward and the omo-hyoid forward, and the 
 pole of the gland itself is ligated extracapsularly, in two places. This 
 "polar ligation," introduced in 1909 by Jacobson and Stamm, and 
 adopted by C. H. Mayo, is valuable as it does not interfere with the 
 
692 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 blood-supply to the superior parathyroids, which would be jeopar- 
 dized if the main trunk was ligated; and because it controls the veins 
 and lymphatics and also destroys most of the vasodilator nerves 
 entering the lateral lobe. This polar ligation thus becomes what 
 Delore and Alamartine call an angeio-neurectomy. The inferior 
 thyroid artery is best ligated at its origin from the thyroid axis, since it 
 divides into numerous branches before entering the gland, and separate 
 ligation of these is difficult and exposes the recurrent laryngeal nerve 
 and inferior parathyroid to injury. The artery is exposed by an 
 incision parallel to the clavicle at the posterior border of the sterno- 
 mastoid; the anterior scalene muscle is located, and the thyroid axis 
 found just to its median border. 
 
 Thyroidectomy. — As in the case of simple goitre (p. 687) only one 
 lateral lobe is to be removed. If symptoms persist, half of the remain- 
 ing lobe may be removed at a second operation. Great care in hemo- 
 stasis must be exercised, and the wound must be freely drained. 
 
 Sympathectomy (Jaboulay, 1896). — Excision of both superior ganglia 
 of the cervical sympathetic, effective in overcoming the exophthalmos, 
 has been abandoned by most surgeons, because it has very little influ- 
 ence on the other symptoms. 
 
 Malignant Tumors of the thyroid are not very rare, especially in 
 goitrous regions. Carcinoma is commoner than sarcoma; endothe- 
 lioma also occurs. Clinically, the distinction is not of much impor- 
 tance, since, as A. Kocher says, "By the time malignant goitre reveals 
 its two chief characteristics it is too late for a radical cure." He 
 adds that if the thyroid continues to enlarge after puberty, in spite 
 of appropriate internal treatment, and in the case of any thyroid which 
 begins to grow without any apparent cause after the thirty-fifth year 
 of life, malignant change should be suspected. The two chief char- 
 acteristics of these malignant tumors are irregular growth, and change 
 in consistency. Instead of the nodules being more or less uniform in 
 distribution and size, a few of them will begin to project to an abnormal 
 degree beyond the others, and they will lose their elastic consistency 
 and become firmer and more flesh-like. Pressure symptoms occur 
 earlier than in benign enlargement, because of development of adhe- 
 sions to surrounding structures. Spontaneous pain is not an early 
 symptom, but occurs in malignant growths much sooner than in 
 benign. 
 
 Prognosis. — The prognosis is bad. Metastasis occurs early, and 
 may be the first evidence of malignancy. In carcinoma, and even 
 in histologically benign diffuse adenoma, metastasis to bones is 
 frequent; and Shepherd has observed pulmonary invasion by carci- 
 noma through the internal jugular veins. 
 
 Treatment. — Very early extirpation is the only method that offers 
 any hope of cure. Shepherd says he has completely excised over a 
 dozen thyroids, and never save in one case (repeated operations for 
 recurrence) has seen any evil effects attributable to injury of the para- 
 thyroids though he has taken no care to preser^•e them. But the 
 
SURGERY OF THE ESOI'IIAGUS 003 
 
 j)r()j)hylactic julniinistratiou ot* j)arathyr()i(lin is rccommeiult'd, aiul 
 tho use of thyroid extract may he necessary to prevent myxedema. 
 Trac'heotomy may he necessary in tar nd\ancc(l in()i)eral)le cases; 
 it may prove a difficult operation. 
 
 SURGERY OF THE THYMUS GLAND. 
 
 In some infants acute or chronic dyspnea is due to enlargement 
 of tlie tliymus ghmd, which compresses the trachea. I'sually the 
 enhirged gkmd may be detected by percussion, and its presence 
 should be suspected when tracheotomy fails to relieve the dyspnea. 
 Then the incision may be extended down to the episternal notch, 
 when the thymus (much like an enlarged lymph node) will protrude 
 from the anterior mediastinum, and may be drawn up into the neck. 
 In some cases it has been sutured to the sterno-mastoid muscle to keep 
 it from again becoming wedged in the thoracic opening, but it is better 
 to enucleate it from its capsule and remove as much of it as is easily 
 detachable. The wound should not be drained, for drainage implies 
 infection, and this means death. If the respiratory obstruction is 
 relieved in time, recovery follows. Olivier (1912) has studied the 
 results of 42 thymectomies; of the 15 deaths, 7 w^ere not due to the 
 operation, and 8 were attributed to the secondary tracheotomy. He 
 concludes that subtotal, subcapsular thymectomy is the best treat- 
 ment. 
 
 SURGERY OF THE ESOPHAGUS. 
 
 Foreign Bodies. — There are three points at which a foreign body 
 
 is apt to be arrested: (1) At the level of the cricoid cartilage; (2) 
 where the left bronchus crosses the esophagus; (3) at the cardiac 
 orifice of the stomach. All sorts of things may be swallowed: chil- 
 dren's playthings, false teeth, pieces of bone, and in the insane, even 
 spoons, forks, etc. Large bodies usually are arrested in the pharynx, 
 and often may be extracted with the finger. Bodies with sharp prongs 
 may catch in the esophageal wall at any point, and much damage may 
 be done by forcible attempts at extraction. 
 
 The diagnosis depends on the history, which in infants and the insane 
 may be very uncertain; on the presence of dysphagia; and on the 
 results of examination with esophageal instruments and the .r-ray. 
 It is important to make the diagnosis as soon as possible, before inflam- 
 matory softening or perforation of the esophageal wall occurs. Do 
 not postpone thorough examination until the next day, thinking the 
 diagnosis will be easier then. It will not be. The esophagoscope 
 should be employed whenever available, and if used early, before 
 the mucous secretion is excessive, the foreign body usually can be 
 seen. This is an instrument analogous to the bronchoscope and 
 cystoscope. It is very much safer in skilled hands than the insertion 
 of a bougie, but this may be the only instrument obtainable. 
 
694 
 
 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 Treatment. — By means of an esophagoscope and the special instru- 
 ments employed with it, one skilled in the use of such apparatus 
 frequently will be able to extract the foreign body under the control 
 of the eye. If this is not possible, the surgeon must employ the older 
 and less satisfactory method of introducing an esophageal forceps, 
 probang, or coin-catcher and thus endeavoring to remove the foreign 
 body by the sense of touch. A general anesthetic is required. A coin 
 usually lies transversely in the esophagus, and may be caught by a 
 
 Fig. 734. — Forceps for removing foreign bodies from the esophagus. 
 
 forceps whose blades open in this direction (Fig. 734). If the coin 
 lies very far down in the esophagus the old fashioned "coin-catcher" 
 (Fig. 735) may be more useful. Occasionally a lodged foreign body 
 may be advantageously pushed on into the stomach. It is not safe 
 to make violent or too prolonged efforts at extraction, especially 
 when more than thirty-six hours have elapsed. When all reasonable 
 efforts have failed, or at once if the nature of the impacted body 
 forbids attempts at extraction through the mouth, the surgeon should 
 
 Fig. 735.- 
 
 -Esophageal instruments: 1, Olive tipped bougie; 2, horse-hair probang ; 
 3, coin-catcher; 4, esophageal forceps. 
 
 resort to external esophagotomy if the foreign body is well above the 
 cardiac orifice; if impacted at the latter site, extraction should be 
 attempted by gastrotomy (p. 876). Under the best modern methods 
 it might be possible to perform transpleural esophagotomy. 
 
 External Esophagotomy. — Through an incision along the anterior 
 border of the left sterno-mastoid, with division or downward dis- 
 placement of the omo-hyoid, the esophagus is exposed behind the 
 trachea and on the median side of the great vessels It should be freely 
 
SURGERY OF THE h'SOI'llACUS 095 
 
 separated from the surrounding tissues, and incised on a sound passed 
 from the mouth, after pulling it up into the wound and isolating it 
 with gauze. The foreign body is then extracted with finger or for- 
 cei)s. The incision in the esophagus is tightly sutured with at least 
 two rows of chromic gut sutures, and a drainage tube is passed down 
 to the site of suture, and is not removed for a week. The remainder 
 of the wound is closed in layers. No food should be swallowed for a 
 week or ten days; rectal feeding should be employed, especially saline 
 solution as in peritonitis, but in the case of very weak patients food 
 may be introduced into the stomach by a stomach tube. The prog- 
 nosis is good if the foreign body has been removed within the first 
 thirty-six hours. 
 
 Stricture of the Esophagus usually results from lye burns, and is 
 especially frequent in small children who drink a cupful of the nice 
 white Huid, mistaking it for milk. It may occur also in adults, from 
 ingestion of corrosive poisons. Symptoms of stricture may not develop 
 for several months after the accident. Sometimes they appear rather 
 suddenly, but usually there is a gradual but progressive increase in 
 dysphagia, at first for solids, then for liquids, and finally regurgitation 
 occurs through the nostrils as soon as food is swallowed. In time a 
 pouch may form, and then regurgitation may not occur for half an 
 hour or more after food is ingested. Any inflammatory attack is apt 
 to produce complete obstruction. Weight is constantly lost, and 
 emaciation may become extreme. There is a decided tendency to 
 bronchial and pulmonary disease, owing to regurgitation of decaying 
 food, and death may occur from such intercurrent malady. 
 
 Diagnosis. — The diagnosis is made from the history of the accident, 
 from the symptoms, and from examination of the esophagus. This 
 should be done by the esophagoscope; but if this is not available, 
 an olive-tipped bougie (Fig. 735) may be passed ver}' gently and 
 cautiously; and the existence of a stricture and its site may be thus 
 determined. The x-ray will detect the existence of a pouch if this 
 is filled with bismuth gruel. 
 
 Treatment. — 1. If the stricture is easily permeable to liquid food, 
 it usually will be possible to secure passage of a bougie, especially if 
 this is done under control of vision through the esophagoscope. 
 Many strictures impermeable to blind instrumentation are not imper- 
 meable with esophagoscopy. The danger of perforation, especially if 
 there is a thin walled pouch, always should be kept in mind. Such 
 an accident generally results fatally in a few days from septic pneu- 
 monia or mediastinitis. If a bougie can be passed, gradual dilatation 
 often is possible, as in the case of permeable urethral stricture; but 
 hazardous as is the employment of any force in urethral instrumenta- 
 tion, it is absolutely harmless compared to its use in esophageal work. 
 The safest esophageal sound, when one is used without the esophago- 
 scope, is the olive-tipped bougie, but it is relatively safe only because 
 of its size. The smaller the stricture, the more flexible should be the 
 instrument. Gradual dilatation may be aided by internal esopha- 
 
096 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 gotomy througli the esophagoscope, the edge of the stricture being 
 divided under full view. Subsequent dilatation always should be 
 conducted under control of esophagoscopy. 
 
 2. If the stricture is impermeable to instruments, the treatment 
 depends somewhat upon the amount of nourishment the patient can 
 take. If sufficient nourishment is taken to maintain weight, various 
 expedients may be tried to get through the stricture. The patient 
 may be made to swallow a silver l)all (Abercrombie, 1830) or per- 
 forated shot (Socin, 1889) attached to a string; after resting on the 
 stricture for some hours these may pass through, and thus from day 
 to day larger balls may be used, until a bougie can be passed. These 
 methods are not more effective than esophagoscopic instrumentation, 
 but may be tried when this is not available. External esophagotomy 
 rarely can be recommended, e\en when the upper end of the stricture 
 is accessible through the neck. It is not likely that this method will 
 be successful when esophagoscopy has failed, and it cannot be known 
 that the stricture does not extend all the way down to the cardiac 
 orifice. If weight is being lost, it is useless to postpone a resort to 
 gastrostomy (p. 877). When the stomach is opened, attempts may 
 be made to pass an instrument through the stricture from below, 
 and these occasionally are successful. But if the patient is very weak 
 it is better not to prolong the operation, but merely to establish an 
 opening in the stomach as rapidly as possible. Stamm's or Senn's 
 method is the best for these cases. It usually happens that the stric- 
 ture becomes permeable after the esophagus has had a rest for some 
 weeks, while food is being introduced through the gastric fistula. 
 This is analogous to the usual course of impermeable urethral stric- 
 tures after the performance of Cock's operation (p. 1026). When the 
 stricture becomes permeable, a string may be passed through it from 
 the mouth; then by extracting the other end through the gastric 
 fistula, the stricture may be cut by a sawing motion, while the esopha- 
 gus is kept taut to prevent damage to its walls (Abbe's method, 1893) ; 
 or the surgeon may adopt von Hacker's method (1894) of retrograde 
 dilatation by drawing through the stricture gradually increasing 
 sizes of rubber tubing, at intervals of a few davs ("Sondierung ohne 
 Ende"). 
 
 3. If the stricture remains impermeable even after gastrostomy, 
 there are still several plans of treatment which may be adopted. 
 Maffei (1906) in two cases successfully exposed the esophagus by the 
 transpleural route, and found that the stricture became permeable 
 as soon as he had released the peri-esophageal adhesions ; the esophagus 
 was not opened at all. Roux (1907) and Herzen (1908) have formed 
 an artificial esophagus by transplanting beneath the skin of the 
 sternum a loop of the upper jejunum, excluded from the intestinal 
 tract. This is to be attached above to the cervical esophagus, and 
 below to the stomach. Herzen's name for this delicate procedure, 
 which is completed in several sittings, is "ante-thoracic esophago- 
 jejuno-gastrostomy." Willy Meyer (1913) has followed Jianu and 
 
HVRCERY OF THE ESOl'llAGUS ()07 
 
 Uocpkc ill iitiliziii»i; a llii]> t'roiii the <:;r('at('r ciirNiitiin' ol' (he stoiiiacli, 
 to ('(Histriict a now ])rc-stt'riial (•s()|)lia<,nis. 
 
 Congenital Imperforation of the Esophagus is a rare iiialtorination 
 ill wliicli tlif gastric end of the eso]jlia^ns usually empties into the 
 bronchus, and the pharyngeal end terminates in a l)lind pouch. Tiie 
 hal)\' sutlers from recurring attacks of sutt'ocation due to regurgi- 
 tation of gastric contents into the air passages; food swallowed is at 
 once regurgitatefl. The best treatment is jjerforinance of jejiino.S'toniy 
 (]). 878), for the purpose of introducing nourishment, as advised by 
 Demoulin (1904). Should the infant survive (which is unusual) 
 treatment as for impermeable stricture of the esophagus should be 
 attcm])tcd later. 
 
 Diverticula of the Esophagus may be congenital or acquired. 
 The ac(|uirc(l diverticula are due either to traction from without 
 (usually from adhesions to bronchial lymph nodes, etc.), or to pressure 
 from within. The irariion diverticula rarely produce symi)toms, as 
 their lumen is oblique or horizontal and the orifice is directed down- 
 ward (Zenker, 1878); food is not apt to collect in them, and often 
 they are found unexpectedly at autopsy. But occasionally during 
 life perforation occurs. Pressure diverticula, well studied by Halstead 
 in 1904, constantly produce symptoms during life, from accumula- 
 tion and regurgitation of food. Sometimes during meals a palpable 
 tumor appears in the left side of the neck, and can be emptied by 
 pressure. Often the earlier part of a meal will be swallowed more 
 easily than the latter part, because gradual filling of the pouch causes 
 obstruction of the esophagus. The pouch is found most often to 
 spring from the posterior wall of the esophagus in the median line, 
 just below the pharynx. A bougie sometimes will be arrested in the 
 pouch, and sometimes will pass on into the stomach, and thus the 
 condition may simulate a spasmodic stricture. But if one bougie 
 is arrested in the pouch, it may be possible to pass another alongside 
 of it into the stomach. The diagnosis is aided by esophagoscopy and 
 by the use of the x-ray after filling the pouch wuth bismuth gruel. 
 
 Treatment. — If the diverticulum is accessible from the neck, it should 
 be exposed from the left side, and excised. The stump is treated as 
 the appendix stump (p. 857), and the wound treated as in external 
 esophagotomy (p. G94). 
 
 Dilatation of the Esophagus, as a whole, usually is secondary to 
 what has been described as cardiospasm, w^hich is now believed to be 
 not a spastic condition of the cardiac orifice of the stomach, but of 
 the esophagus just above the cardia. The cause of the "cardiospasm" 
 has not always been determined, but in some cases gross esophageal 
 lesions (ulcer, carcinoma, etc.) have been found. 
 
 Symptoms. — The symptoms are those of slowly oncoming and never 
 entirely complete obstruction to food. In the early stages there is 
 a feeling of fulness after eating, with an uneasy sensation in the 
 epigastrium or behind the sternum; the patient eats very slowly, 
 and requires much liquid to wash the food down; final entrance of 
 
698 SURGERY OF THE FACE, MOUTH, AND NECK 
 
 food to the stomach may be accomphshed only after the patient has 
 retired to a corner and urged the food down by deep breathing, gulp- 
 ing, or curious contortions of the arms and body. Later, regurgitation 
 occurs immediately after swallowing; but when full dilatation has 
 developed food may be retained for several hours. The regurgitated 
 food is not sour, as it would be if vomited after lying in the stomach. 
 
 Diagnosis. — Diagnosis is based on the symptoms, and on the exclu- 
 sion of organic stricture by esophagoscopy or by passage of a bougie. 
 A bougie may be arrested near the cardiac orifice, but usually passes 
 through after temporary arrest. A skiagraph, made after ingestion 
 of bismuth gruel, also is helpful. 
 
 Treatment. — The most satisfactory treatment is forcible divulsion 
 of the cardia. This can be done by instruments passed by mouth, as 
 in the methods of Sippy and of Plummer. The apparatus consists 
 of a rubber bag about 10 cm. long, encased in a silk bag which limits 
 the possible distention to a circumference of 15 cm. Dilatation is 
 produced by an air-pump. The treatment usually must be repeated 
 several times before complete relief is secured. No anesthetic is 
 necessary. In some cases divulsion of the cardia may be done after 
 gastrostomy. 
 
 Carcinoma. — Carcinoma is the most frequent disease of the esoph- 
 agus. It occurs oftenest in males, in the decline of life. About 50 
 per cent, of cases are near the cardia, 40 per cent, at the bifurcation 
 of the trachea, and only 10 per cent, at the cricoid cartilage. It 
 probably often develops in an ulcer or erosion. Its onset is insidious, 
 but when once symptoms develop, they progress rapidly. The chief 
 characteristic is increasing difficulty in deglutition, for which no cause 
 can be found in the patient's clinical history. Syphilitic stricture is 
 rare but must be excluded. The diagnosis from aortic aneurysm 
 often is exceedingly difficult. In carcinoma very early and great 
 enlargement of the bronchial lymph nodes may occur; there often are 
 pressure palsies of the recurrent laryngeal or sympathetic nerves; and 
 dyspnea may exist. Referred pain is common, and erosion of the 
 vertebrae and even paraplegia may develop before symptoms of 
 esophageal obstruction are marked. Pulmonary complications are 
 frequent. Passage of a bougie may provoke hemorrhage. Esopha- 
 goscopy is important. The prognosis is very bad. Death u.sually 
 occurs in a year from the date of diagnosis. 
 
 Treatment. — When thoracic surgery becomes better developed, and 
 especially by the use of anesthesia by intratracheal insufflation, it will 
 be possible to explore the seat of disease, with the hope of doing 
 a radical operation. This has been accomplished once successfully, 
 by Torek (1913). In most cases only the palliative operation of gas- 
 trostomy is successful, but this should not be employed so long as 
 liquids can be swallowed. Whenever possible, before this operation 
 is done, the intestinal tract should be cleared of the masses of stagnant 
 feces usually present. 
 
CHAPTER XX. 
 
 SURGERY OF THE BREAST, THE CHEST WALL, THE 
 LUNGS, AND THE DIAFHI^AGM. 
 
 SURGERY OF THE BREAST. 
 
 Congenital Anomalies. — The only one of these that is of much 
 surgical interest is the existence of supernumerary breasts, a con- 
 dition known as poJymastia. Either sex may be affected, but it is 
 said to be slightly more common in males. The extra glands may be 
 situated almost in any part of the trunk, most often near the axilla 
 or groin (Fig. 730), or in a line joining these two sites. The accessory 
 glands may be of various sizes. Sometimes only a supernumerary 
 nipple is present (polythelia), (Fig. 737), and sometimes a mass of 
 mammary tissue without a nipple exists in the subcutaneous tissues. 
 In men this resembles a lipoma; but in women its true nature is 
 revealed by its increase in size during menstruation, or pregnancy, 
 or lactation. Any supernumerary mamma which causes annoyance 
 should be excised. 
 
 ll"'' 
 
 
 
 1 
 
 ^^^^H 
 
 9 
 
 ^^B||C 
 
 
 Fig. 736. — Supernumerary mamma (or lipoma?) in adult male. Since puberty has 
 had this mass which at times used to discharge a little whitish fluid. Note the nipple- 
 like projection, but absence of pigmentation. Episcopal Hospital. 
 
 Affections of the Nipple. — Sometimes a nipple fails to develop 
 properly, especially where tight underclothing is constantly worn. 
 During pregnancy care should be taken to favor its development 
 by drawing it out, gently; and it should be further prepared for 
 suckling by frequent cleansing and application of astringent washes, 
 of which none is better than dilute alcohol. During lactation, 
 
roo 
 
 SURGERY OF THE BREAST 
 
 not only should the condition of the infant's mouth be watched, 
 but the nii)ple should be washed with warm water and castile soap 
 before and after suckling, and if any tendency to irritation exists 
 it should be dustcfl with boric acid or borated talcum powder after 
 cleansing after each act of nursing. Fissures and excoriatiuris of the 
 nipple, which are extremely painful and interfere with suckling, 
 
 should be treated by unremit- 
 ting attention to cleanliness. 
 The use of a nipple shield or 
 breast pump, so as to prevent 
 direct contact of the child's 
 mouth, is necessary, and in 
 most cases the act of suckling 
 must be discontinued tempor- 
 arily. The excoriations and 
 fissures, after gentle cleansing, 
 should be painted with dilute 
 tincture of iodin (1 part to 5 
 of water), or a weak glycerite 
 of tannin, and then dusted with 
 boric acid powder. The use of 
 ointments is injurious. 
 
 Acute Mastitis. — Though in- 
 flammation of the breast occa- 
 sonally develops in the newborn, 
 and in boys and girls at puberty, 
 it occurs oftenest in nursing women, being in most cases an ascending 
 infection from the nipple by way of the ducts or the lymphatics. It 
 is most frequent in primiparse, especially in those with poorly developed 
 nipples, which have received insufficient attention during pregnancy. 
 It occurs most often within a few days of delivery, or not until the 
 end of lactation. 
 
 Acute mastitis is characterized by the usual signs of inflammation, 
 which are confined in almost all instances to one or more lobes of the 
 gland. Diffuse inflammation is rare. The regions affected feel 
 tough and doughy, and tenderness is not very marked. The skin is 
 unaltered and moves freely over the breast. There is a heavy feel- 
 ing, with dull pain, and occasionally shooting pains. In a puerperal 
 woman this stage is described as "caked breast," because of the accu- 
 mulation and inspissation of the milk owing to obstruction of the 
 galactophorous ducts b}' the inflammatory changes. 
 
 Treatment. — Treatment consists in attention to the nipple, which 
 may be fissured or excoriated, and to the patient's general health. 
 The child should not be allowed to suckle from the affected breast 
 until resolution is complete. Daily light massage of the area affected 
 usually is efficacious in overcoming the stagnation and promoting 
 resolution without suppuration. Some ointment with lanolin as 
 a basis should be used in connection with the massage. In the 
 
 Fig. 737. — Polythelia; a supernunifrary 
 nipple near right nipple. Orthopgedic Hos- 
 pital. 
 
MAMMARY ABSCESS 
 
 701 
 
 intervals the breast should he covered with heiladoiina and mercury or 
 other sorhet'acient ointment, and well supported with a compressory 
 handa;i;e or hinder. Meantime a breast pump nnist l)e emi)loyed. 
 Another valuable aid in resolution is passive hyperemia, according 
 to Bier's method, with a cupping glass applied over the nipple, as 
 originally introduced by (Miassaignac. 
 
 Mammary Abscess. — Mammary abscess usually develops as a 
 sequel of stagnation mastitis (caked breast). The area affected 
 becomes more tender; dusky redness appears in the skin; this becomes 
 adherent to the deeper structures; and the abscess is ready to be 
 oi)ene(l (Fig. 7.SS). Before this occurs, however, destruction of the 
 mannnary tissue may be very 
 extensive, and it is very im- 
 portant to recognize the onset 
 of suppuration as early as pos- 
 sible. The fluid expressed from 
 the nipple by massage, in the 
 stage of caked breast, should be 
 collected from time to time on 
 gauze. The milk will be ab- 
 sorbed; but if there is any pus 
 in the fluid, it will remain on 
 the surface of the gauze and 
 stain it yellow. This is known 
 as Budin's sign. As soon as 
 suppuration [is suspected, the 
 inflamed area should be incised. 
 This incision should be made 
 directly over the area affected, 
 and in a line radiating from 
 the nipple, so as to injure as 
 few of the milk ducts as possible 
 and thus decrease the chance of a 
 lacteal fistula developing. The earlier and more freely this incision 
 is made, the less danger there is of the pus burrowing among the 
 glandular tissue. If delayed, various pockets of pus will be found, 
 and these will have to be broken open by the finger to ensure 
 free drainage. Tube drainage is desirable until the discharge of pus 
 ceases. An abundant dressing of hot moist gauze (soaked in boric 
 acid or normal saline solution) is required to absorb the discharge. 
 After drainage is discontinued the wound closes rapidly in most cases, 
 if incision has been made early enough; if it has been delayed or not 
 sufficiently free, secondary abscesses may form. Very rarely, when 
 the breast is riddled with abscesses and discharging sinuses, amputa- 
 tion is required. 
 
 Chronic mammary abscess is not very rare; it may be subacute or 
 frankly chronic. The former usually arises during lactation, as the 
 result of an unresolved stagnation mastitis; or after an imperfectly 
 
 Fig. 738. — Abscess of left breast in a 
 primipara. Age twenty years, nursing a 
 baby three months old. Duration of 
 mastitis ten days. Incised and drained by 
 tube; in nine days only a granulating sur- 
 face remained. Episcopal Hospital. 
 
702 SURGERY OF THE BREAST 
 
 drained acute abscess. Those which develop independently of 
 lactation are much more unusual, and may be due to suppuration in 
 a hematoma (from trauma), or to excoriations, patches of eczema, 
 etc., on the nipple or in the inframammary fold. The .symptoms are 
 those of chronic mastitis (see below), but the yhysical signs resemble 
 more those of a neoplasm (p. 711), and the diagnosis, which often is 
 impossible, rests on the history of the case, and the detection of some 
 source of infection. Treatment: Exploratory incision, best by the 
 submammary incision (p. 711), usually is necessary for diagnosis; 
 and the abscess wall which often is thick and indurated, should then 
 be removed in entirety. 
 
 Submammary Abscess. — Suppuration may occur in the cellular 
 tissue between the pectoral muscle and the breast. Usually this is 
 caused by an abscess in a deep lying lobe of the mammary gland, 
 where pointing occurs tlirough the deep layer of superficial fascia 
 in which the gland lies, instead of tlirough the overlying skin; indeed, 
 prolongations of the gland may extend normally into the retro- 
 mammary space. In a few cases, however, submammary abscess is 
 secondary to axillary lymphadenitis or to diseases of the pleura, 
 caries of the ribs, etc., which usually are tuberculous in nature. The 
 diagnosis of submammary abscess is not always easy; the gland is 
 prominent, raised away from the chest by the suppuration beneath ; 
 but owing to the deep seat of the suppuration the ordinary physical 
 signs of an abscess may not be present. The abscess may simulate 
 a small hard tumor, especially as axillary adenitis often is present. 
 Treatment consists in evacuation of the pus by a curved incision 
 beneath the lireast, with free drainage until the discharge ceases. 
 
 Subpectoral Abscess. — See p. 730. 
 
 Chronic Mastitis. — In addition to the acute infectious mastitis, 
 already described as most frequent in puerperal women, there occurs 
 a form of circumscribed subacute or chronic mastitis, probably also 
 infectious in origin, in women at almost any age, but usually in those 
 between twenty and thirty, or in those approaching the menopause, 
 and among the unmarried nearly as frequently as in those who have 
 borne children. They come to the surgeon complaining of a painful 
 and tender area in the breast, about which they not infrequently 
 seem unduly alarmed. Examination shows slight or no enlargement 
 of the breast, and palpation of the gland with the hand, pressing it 
 flat against the chest wall, makes it clear that there is no tumor 
 present. If the gland is examined between the thumb and fingers, 
 one or more irregularly-shaped, ill defined masses may be felt; these 
 usually seem to radiate from the nipple, and undoubtedly are in the 
 glandular tissue. The overlying skin is unaltered, and the breast 
 moves freely upon the chest wall. The mass may be exquisitely 
 tender, and the seat of shooting or neuralgic pains. The overlying 
 skin may be highly hyperesthetic. To such a condition in neurotic 
 women, the term inastodynia or neuralgia of the breast has been applied. 
 This is the " irritable tumor of the breast" of Sir Astley Cooper (1829), 
 
GALACTOCELE 703 
 
 thou«,fli it is also i)()ssihlr that sucli a coiulition iiiif^lit hv caused l)y a 
 false neuroma (p. 293) as iu other ])orti()ns of the body. Pain referred 
 to the breast in eases of intereostal neuralgia should not l)e confused 
 with true mastodynia. In most ciuses of luaModynia both hreasia are 
 affected, but only one out of a number of such lumps may give 
 symptoms. They may produce symptoms during menstruation or 
 pregnancy, and not at other times. 
 
 The cause of these changes is obscure, and the subject is not much 
 clarified by the various hypotheses which have been advanced. If 
 the woman has borne children, the natural assumption is that these 
 masses are the result of clianges occurring during lactation; they may 
 be the remains of an area of stagnation mastitis (caked breast) which 
 was so sHght as to have been overlooked at the time. In virgins, 
 it may be assumed that the breast has been subject to forgotten 
 trauma; or that its condition is connected with some functional 
 derangement of the pelvic organs. 
 
 The pathological anatomy of the condition is practically unknown, 
 as operation has been undertaken very seldom. Lecene (1911) 
 examined a fragment of tissue from such a specimen, and found 
 lesions which corresponded to a functional hypertrophy of the acini, 
 w^ith lymphatic stasis, and slight degree of congestion; he concluded 
 that they were trophic or vasomotor in origin, and in no way truly 
 inflammatory. 
 
 The clinical course of the disease is various. Usually the symptoms 
 subside under conservative treatment, and the masses do not enlarge 
 or give any other evidence of their presence; in many cases they 
 almost disappear. In some cases, however, a cystic transformation 
 supervenes, the pathogenesis of wdiich is uncertain; probably it is 
 neoplastic in character, and not due to inflammatory compression 
 of the gland ducts (p. 712). 
 
 Treatment. — Firm support, by bandaging or binder, or even by 
 adhesive plaster strapping, should be provided, unless the tenderness 
 is so excessive as to render this impossible. Belladonna and mercury, 
 compound iodin or ichthyol ointment, applied to the breast, leaving 
 the nipple uncovered, is useful in relieving tenderness. When tender- 
 ness sul3sides, gentle massage should be given. The condition of the 
 pelvic organs should be determined, and suitable treatment insti- 
 tuted. Tonics, good food, and general hygienic measures should not 
 be neglected. 
 
 In addition to this circumscribed form of chronic mastitis, some 
 writers recognize a diffuse chronic mastitis. I have discussed this 
 subject at p. 709. 
 
 Galactocele. — Closely related pathologically with chronic mastitis 
 is the condition described as galactocele, formerly considered a 
 retention cyst of the breast. The cyst wall, however, is not composed 
 of secreting cells, but is formed by a condensation of surrounding 
 connective tissues. Lecene (1911) holds that it is merely a chronic 
 abscess into which milk ducts have opened secondarily; others, with 
 
704 SURGERY OF THE BREAST 
 
 less probability as it seems to me, contend that the primary con- 
 dition was dilatation of the lactiferous tubules, and that the cyst 
 is formed by their rupture into the surrounding tissues. Galactocele 
 is quite rare, and occurs most often during lactation. A small lump 
 forms quite suddenly; usually it is in the region of the areola, but 
 may be more deeply seated. Sometimes several cysts exist. The 
 mass is not tender or painful, feels semi-cystic, and is quite movable 
 beneath the skin and on the underlying pectoral fascia. In many 
 cases pressure on the swelling causes milk to exude from the nipple, 
 and the cyst may thus be emptied. In other cases its contents become 
 inspissated, and resemble butter or cheese, when there may be pitting 
 on pressure, which is a very characteristic sign. Lacteal calculi have 
 been described in some of these cases, but modern writers consider 
 the reports apocryphal. 
 
 Treatment. — A galactocele should be excised, and the wound 
 sutured. Incision, followed by packing, is followed by tedious cure, 
 and the cicatrix is more conspicuous. 
 
 Tuberculosis of the Breast is a rare affection. It occurs almost 
 solely in women from thirty to fifty years of age, usually those who 
 have borne children. The infection may be an ascending one from 
 the nipple, by way of the ducts or lymphatics; may be hematogenous; 
 or may arise by extension from an adjacent focus in the ribs, sub- 
 mammary lymphatics, or pleura. ]\Iany scattered nodules may be 
 found, or one or two large masses. The tendency toward the forma- 
 tion of cold abscess and toward spontaneous fistulization is more 
 common in the latter form. Until this stage is reached the diagnosis 
 is nearly impossible clinically, and even after these developments 
 it is not always easy. The axillary lymphatics usually are enlarged. 
 If secondary infection follows fistulization, the general health rapidly 
 deteriorates. 
 
 Treatment. — The only satisfactory treatment is amputation of 
 the breast, and extirpation of the axillary lymphatics. The operation 
 resembles that for carcinoma, but it is not necessary to remove the 
 pectoral muscles unless they are manifestly diseased. 
 
 Syphilis. — Syphilis may affect the skin over the breast, or the 
 mammary gland itself. A chancre presents the same characters 
 here as elsewhere; it occurs almost exclusively in women who act as 
 wet-nurses to foundlings or other infants with congenital syphilis; 
 the lesions may be multiple and often both breasts are affected. 
 Prophylaxis usually is possible, and a syphilitic child never should 
 be nursed by another than its own mother, who is immune to infection 
 in this way^ according to Colles's law (p. 998). Secondary lesions of 
 syphilis, especially mucous yatches, often may be found in the sub- 
 mammary fold when not visible elsewhere. Sometimes in this stage 
 of syphilis the mammary glands become swollen and painful, the 
 condition being known as diffuse syphilitic mastitis. Gumma is the 
 most frequent lesion of syphilis which affects the glandular tissue 
 of the breast. It is quite rare, however, and is difficult to distinguish 
 
TUMORS OF Tilt: BREAST 705 
 
 from sonic hciiij^n tumors imlt'ss a distinct history ot" sypliiiis can 
 be obtained, or the Wasscrmann test is positive, or when the bene- 
 ficial cfVcct of antisyphiiitic treatment becomes apparent. Fortunately 
 the iodides are \-er\ rapidly curative. 
 
 Tumors of the Breast. — The subject of tumors of the mammary 
 f,dan<l usually is a difficult one for the student, because owing to the 
 complexity of its structure the tumors growing in it are of many 
 diHerent kinds derived from epithelial or fibrous tissues. Thus 
 there may be adenomatous, papillomatous, epitheliomatous, cystic, 
 and even sarcomatous tumors. And as in most of these tumors both 
 the epithelial and fibrous elements seem to participate almost equally 
 in the blastomatous .transformation, it is rare for a pure adenoma, 
 or a pure fibroma to develop. Instead we find many combinations 
 of fibrous, adenomatous, cystic, papillomatous, and other conditions. 
 The following classification, based in part on that of J. Collins Warren 
 (1905), seems to me the most satisfactory. The relative frequency 
 of the different growths is indicated by the attached percentages. 
 
 Blast omatoid Conditions 
 
 (a) P'ibro-adenomatosis, .2 per cent. I 16 per cent 
 
 (6) C\-st-adenomato.sis, 1.5.8 per cent. / ^ 
 
 Benign Tumors 
 
 1. P'ibro-adenoma, 9.6 per cent. 
 
 / \ T) • 1 . 1 cu / Intracanalicular 1 
 
 (a) Periductal fibroma > pericanalicular \ 
 
 (b) Periductal myxoma 
 
 (c) Periductal sarcoma j^ 12 per cent. 
 
 2. Cyst-adenoma, 2.4 per cent. 
 
 (a) Fibro-cyst adenoma 
 
 (b) Papillary-cystadenoma 
 .3. Simple Adenoma j 
 
 4. Lipoma | 
 
 5. Angeioma [ 1 per cent. 
 
 6. Endothelioma 
 
 7. Enchondroma 
 
 Malignant Tumors 
 
 1. Sarcoma, 1 per cent. 
 
 2. Carcinoma, 70 per cent. 
 
 (a) Adenocarcinoma 
 
 (6) Solid-celled Carcinoma 
 
 1. Scirrhous Carcinoma c 71 per cent. 
 
 2. Carcinoma Simplex 
 
 3. Medullary Carcinoma 
 
 (c) Paget 's Disease of the Nipple 
 
 (d) Carcinomatous Cyst 
 
 Before discussing blastomas, or tumors proper, it is necessary to 
 say something of certain blastoniatoid conditions Avhich occur in the 
 breast. The general characters of these conditions were discussed 
 in Chapter IV. 
 
 In the mammary gland there occur lesions the true nature of which 
 is still in much dispute. As to one condition especially, while it may 
 be said that surgeons acknowledge its existence and are agreed on 
 45 
 
706 SURGERY OF THE BREAST 
 
 its clinical features; and while pathologists agree on the histological 
 picture; yet the former cannot agree on a name which they consider 
 descriptive, and the latter cannot agree on the interpretation of 
 what they see under the microscope. This condition is known in 
 some quarters by the name "chronic cystic mastitis." Another 
 condition the classification of which is disputed, is described as 
 ''idiopathic hypertrophy" of the breasts. Now when one looks at 
 the classification of tumors given above, he sees that under the benign 
 growths the two main types, which are fibro-epithelial in character, 
 are (1) Fibro-adenoma, and (2) Cystadenoma. Were he to look 
 around for blastomatoid conditions in his patients corresponding 
 to these tumors, he would find that such conditions actually occur; 
 and it would be a matter of surprise that no one had previously 
 recognized that idiopathic hypertrophy of the breasts corresponds 
 to a fibro-adenomatosis, and that chronic cystic mastitis corresponds 
 to a cystadenomatosis. Let us look then at these two conditions 
 more narrowly, and see what they are: 
 
 Fibro-adenomatosis. — Diffuse or "idiopathic hypertrophy" of the 
 breasts may appear first during pregnancy; but the disease in most 
 cases affects virgins soon after the age of puberty. Albert (1910) 
 has collected 18 cases of the former and 52 of the latter variety. 
 It is doubtful whether the conditions are pathologically the same: in 
 the cases which develop during pregnancy the glandular elements 
 are markedly increased, whereas in the virginal form it is a pure 
 fibromatous over-growth, the undeveloped glandular elements being 
 practically unchanged. This difference may be due merely to the 
 undeveloped condition of the virgin breast. 
 
 Both breasts are enlarged in almost all cases (62 out of 70 cases 
 collected by Albert), and they may reach an immense size. In Durs- 
 ton's historic case, recorded in 1669, the weight of one breast, removed 
 postmortem, was 64 pounds. Seldom, however, does the weight 
 exceed 8 to 12 pounds. There are no symptoms other than dis- 
 comfort from the size and weight, but the breasts may increase 
 and decrease slightly in size from time to time. The form which 
 arises during pregnancy sometimes subsides spontaneously when the 
 pregnancy and lactation are ended; but the virginal form progres- 
 sively increases. The growth is slow, and the disease extends over 
 many years. Ver\' rapid enlargement of one breast alone, though 
 it bear the character of a simple hypertrophy, always should rouse 
 suspicion of malignancy, especially sarcoma. 
 
 Treatment. — Treatment of the condition which arises during preg- 
 nancy always should be palliative; this consists in the recumbent 
 position, with elevation and compression of the breasts; the use of 
 sorbefacient ointments locally; the internal administration of potas- 
 sium iodide or thyroid extract ; repeated catharsis, and a dry diet. If 
 no improvement is noted after pregnancy has terminated, and in the 
 virginal cases as soon as the diagnosis is assured, one of the breasts 
 should be amputated. In a few cases the remaining breast has then 
 
( ' VST A DENOMA TOSIS 71)7 
 
 somewhat (l('(Tcas(>(l in size. If it docs not, it should he removed 
 sul)se((ueiitl\'. 
 
 Cystadenomatosis or Abnormal Involution of the Breast. In \SS'A 
 Uechis (k'scrihed in detail a "cystic disease of the breast," wjiich 
 he had studied first over twenty years before, and which had been 
 recognized by F. Kcinig (1<S75), by Brodie (184G), and by Sir Astley 
 Cooper ( 1S29). In more recent times it has l)een studied by Schimmel- 
 i)usch (l.SOO), who named it cysiadenoma; by Konig (1893), who 
 called it mast His chronica cystica; by J. C. Warren (1905), for whom 
 it is an abnormal involution of the breast; and by Bloodgood (1900). 
 who called it senile parenchymatous hypertrophy. These are only a 
 few of the names by which it is known. It matters little by what 
 name it is called, so long as people understand what is referred to; 
 and I ha\e not had the temerity to select a new name for it, but have 
 followed Warren, who restored it to the position in the nosology 
 of breast lesions to which it was originally assigned by Sir Astley 
 Cooper: a pathological change similar in nature to that of diffuse 
 virginal "hypertrophy," though characterized by epithelial (cystic) 
 growth, where the latter is characterized by fibrous. 
 
 The disease is very frequent, but may exist for years without 
 producing symptoms Though seen oftenest in women from thirty 
 to fifty years of age, this is no proof that it has not had an obscure 
 beginning at a much earlier age.- Occasionally it comes under obser- 
 vation shortly after puberty, when the mammary glands begin to 
 develop; but is much more frequently seen when their functional 
 activity is drawing to a close. It is rare after the menopause. In 
 most cases both breasts are diseased, though only one may produce 
 symptoms. The disease appears to be as common in the unmarried 
 and in those who have borne no children as in those in whom the 
 mammary glands have been functionally active. 
 
 Symptoms and Clinical Course. — The woman consults a physician 
 usually because she has an uncomfortable feeling in the breast, and 
 perhaps because she has noticed that it has grown larger, or because 
 by accident she has felt a lump in it. On examination the breast 
 generally is found enlarged, but not unduly pendulous. No lump or 
 tumor is visible. If the gland is picked up in the thumb and fingers, 
 it may seem that there is a considerable tumor in it, but if the hand 
 presses the gland fiat against the chest it is evident that there is no 
 tumor at all. There should now be undertaken what Astley Cooper 
 calls a very careful and nice manipular examination. What is detected 
 is very characteristic: seemingly each individual lobule can be felt 
 distinctly, enlarged and hardened, and moving freely upon the other 
 lobules. The breast feels as if it were full of lead shot, varying in 
 size from pin-head to grape-size. Early in the disease no large masses 
 are felt. These little, hard masses are mostly in the centre of the 
 gland, beneath the nipple and areola. Pressure on the breast causes 
 no pain, but an occasional shooting pain occurs. The overlying 
 skin is normal. There is no discharge from the nipple. The axillary 
 
708 SURGERY OF THE BREAST 
 
 nodes are not palpable. If now the other breast be examined, almost 
 invariably a similar condition, perhaps not so pronounced, will be 
 found in it. 
 
 If such a breast is amputated, it is found that the shot-like particles 
 which felt so hard, and which were distributed through all parts of 
 the gland, are not solid at all, as one might imagine; they are minute 
 cysts, tensely filled with clear or slightly yellow or even brownish 
 fluid. The cyst walls are smooth; there are no intracystic growths. 
 Microscopical examination shows that the cysts are lined with gland- 
 ular epithelium, which shows little if any tendency to proliferation 
 beyond the capacity of the basement membrane ; seldom in any place 
 is there more than one row of cells on the basement membrane, and 
 never is there any papillomatous out-gro^^i;h into the cavity of the 
 cyst. The stroma of the breast is a dense white mass of fibrous 
 tissue, and there is no single area in the entire breast which can be 
 said to be free of disease. The change is not one of tumor formation, 
 but a general blastomatoid over-growth. 
 
 If no treatment is instituted the disease may progress; or after a 
 few years, a secondary atrophy may set in, the breast decreasing in 
 size, all symptoms subsiding, and the patient remaining well. This, 
 however, is rare; in most cases the disease is progressive. In one 
 portion of the breast a larger, more clearly outlined mass may be felt, 
 and sometimes there are two or tliree such masses. They may be 
 visible as rounded projections beneath the skin. When very large 
 they may give a sense of fluctuation. They are cysts; and have 
 formed by the gradual distention of one or more of the small cysts 
 which have been present for years. In other parts of the breast these 
 small cysts may still be felt on "nice manipular examination." At 
 this latter stage of the disease, there sometimes is a glairy or clear 
 yellowish discharge from the nipple; pressure on the cysts may cause 
 this fluid to appear. The cysts may oscillate in size from month to 
 month, and at times the axillary lymph nodes may become palpable, 
 and again this swelling may subside. Pathological examination at 
 this stage may show the cysts still simple in nature, with smooth 
 lining wall, but in the vast majority of cases the cysts, at least the 
 larger ones, contain intracystic papillomatous out-growths. 
 
 If still no treatment is instituted, some of the clinical characteristics 
 of malignancy may be noted. The nipple may seem retracted into 
 the gland, but usually can be drawn out easily, the skin may become 
 adherent, not by cellular infiltration, but by condensation of the 
 intervening tissues ; and at last one of the cysts may grow so large as 
 to cause pressure necrosis of the overlying skin. The contents of the 
 cyst will then be discharged, and the cyst, if it contains no papillo- 
 matous out-growths, may collapse, and in rare cases healing may 
 occur. If the cyst contains papillomatous out-growths, these may 
 protrude tlirough the opening formed in the skin by sloughing, 
 and a fungus growth will develop which it may be very difficult to 
 distinguish from a malignant tumor. At the present day, however. 
 
C VST A DEXOMA TOSI.S 709 
 
 it is almost an unknown tiling for the disease to he allowed to 
 reach this advanced sta<;e, as the breast is removed at an earlier 
 period. 
 
 Another, and probably more frequent contingency may arise. 
 Instead of the disease taking on a cystic type of development, which 
 usually is quite benign, it may undergo an adenomatous transforma- 
 tion, in-growths occurring from the ducts or cyst walls into the sur- 
 rountling stroma; and in about 10 or 15 i^cr cent, of cases the disease 
 terminates as a carcinoma (Speese, 1910). It is on this account that 
 its early recognition and proper treatment are so important. 
 
 Diagnosis. — In its onset this affection of the })reasts resembles 
 chronic mastitis, and by many it is still considered infectious in origin 
 There seems to be no doubt that previous attacks of mastitis pre- 
 dispose the patient to the development of this disease. And in some 
 cases it is nearly impossible to say ofi'-hand that this is a case of 
 diffuse chronic mastitis and not one of "abnormal involution," or 
 vice versa. I have preferred to discuss the disease entirely in one place, 
 and for this reason have described only a localized and not a diffuse 
 form of clironic mastitis (p. 702). From cystadenoma of the breast 
 (p. 712) its differentiation also is difficult especially in the later stages; 
 but as a rule even in such cases the dift'use nature of the process is 
 evident. While the cystadenoma is at first a localized growth, it 
 increases in size much more rapidly than does the breast which is 
 the seat of diffuse cystadenomatosis; and only after the latter con- 
 dition has existed for many years will cysts be present commensurate 
 in size with those of a cystadenoma of some months' duration. As 
 in this stage the treatment for both affections is the same (amputation 
 of the breast), the distinction is not of great importance. 
 
 Treatment. — 1. If the woman is young (under thirty-eight years), the 
 cystadenomatoid change recently discovered and presumably of slow 
 growth, she should be kept under strict surgical observation, a careful 
 manipular examination of the breasts being made at monthly inter- 
 vals. Meantime such general hygienic measures, changes in clothing 
 and habits of life, and attention to menstrual derangements should 
 be enforced as seem indicated. Local treatment has little value, but 
 such as was recommended for chronic mastitis (p. 703) is at least harm- 
 less. If the condition remains stationary, or, still better, if it seems 
 to subside, well and good; no operation is required. If it continues 
 to progress, the breast (often both of them) must be operated on. 
 The operation may be begun by an exploratory incision, as in the 
 method of "plastic resection" of the breast (p. 711); when the gland 
 tissue is exposed and incised, the subsequent course of the operation 
 wdll depend on what is found. If only one or two fairly large cysts 
 are found, and no suspicion of malignancy exists, it is sufficient to 
 excise the cysts and leave the greater portion of the gland intact. 
 If a number of cysts are present the entire breast should be ampu- 
 tated, as described below. If any suspicion of malignancy exists, 
 the axilla should be exposed, cleared, and its contents should be 
 
710 SURGERY OF THE BREAST 
 
 removed in one mass with pectoral muscles, mammary, gland, and 
 overlying skin. 
 
 2. If the woman is past the age of greatest functional activity of 
 the mammary glands (and this age varies in individuals as in different 
 races), it is better to remove the breasts at once, since the probability 
 of actual or subsequent malignant change is much greater at this 
 period of life. 
 
 Whenever the breast is removed it should be most scrupulously' 
 examined macroscopically; any and every area suggesting malignancy 
 should then be studied microscopically by a competent pathologist. 
 Such areas are intracystic papillomatous growths, or areas of greater 
 density or of ulceration in the cyst walls. Only one very minute 
 area such as this maj^ be present in the entire gland, and it is very 
 easily overlooked. The question of malignancy should be decided, 
 as it is vital for prognosis and the patient's peace of mind. 
 
 I place no reliance at all on diagnoses made during the progress 
 of the operation from microscopical study of frozen sections; yet 
 I know that Rodman and other experienced surgeons still deem this 
 method of value. The macroscopical appearance of the breast should 
 be a better guide to the surgeon, and my own judgment agrees with 
 that of Bloodgood and others, that no surgeon should be satisfied 
 to operate on these borderline cases unless he has the skill and 
 knowledge to differentiate clinically at the time of operation between 
 growths certainly benign and those possibly malignant. 
 
 Amputation of the Breast. — An incision is made in the submammary 
 crease, from the anterior axillary fold inward to the parasternal 
 line. The lower edge of the pectoralis major is exposed, and the 
 mammary gland thrown upward on the patient's chest. The gland 
 can then be explored from the posterior surface. If amputation, 
 instead of plastic resection or radical ablation, is determined upon, 
 a curved incision is then made above the breast, joining the ends of 
 that already made. The flaps are dissected up sufficiently to ensure 
 complete removal of all glandular tissue. The wide area over which 
 this iRSiy be spread should be remembered (p. 721). The surface of 
 the pectoralis major is then exposed above and the fascia is dissected 
 from it downward. Bleeding points, chiefly branches of the inter- 
 costals, are clamped as severed. The superficial fibres of the muscle 
 are removed, and the mammary gland is excised in one piece with the 
 nipple and overlying skin, the surrounding fat, and the pectoral fascia. 
 Hemorrhage being controlled by ligature, the wound is closed with 
 interrupted sutures, and provision is made for drainage for a few days. 
 
 Benign Tumors. — Benign tumors of the breast are rare. They occur 
 mostly in young women, from fifteen to thirty years of age, and in 
 almost all cases are fibro-epithelial in type (Ribbert, 1901). They 
 are conveniently divided, as is done by Warren, into two subdivisions: 
 (1) Those in which the fibrous element predominates fihro-adenoma; 
 and (2) those in which the epithelial element is conspicuous — cyst- 
 adenoma. 
 
A7 HRO-A DENOMA TOVS TUMORS 7 1 1 
 
 1 . Fibro- adenomatous Tumors. -These arc particularly character- 
 ized by iic()i)lastic <fr()\vth of the stroma which surrounds the gland 
 ducts; hence they are all described as jwriduvtal tionorff. If the tumor 
 is mostly pure fibrous tissue, like that found in the virgin breast, 
 it is called a periditrtal fibroma; and the fibromatous change may be 
 either intra-canal'intUir in type, or prrianmllculur: in the former 
 case the fibromatous tissue comi)resses and distorts the ducts, so that 
 these api)ear as curved slits or chinks in the microscopical field; 
 while in the peri-canalicular form the normal appearance of the 
 ducts is largely ])reserved. In most cases, instead of a pure fibro- 
 matous tumor, there is myxomatous degeneration of the fibroma, and 
 the growth is known as a periductal viyxoDiu; this is the form most 
 frequently encountered, though prol)ably at an earlier stage the 
 tumor was more purely fibromatous. In rare cases, the stroma of the 
 tumor instead of being fibromatous or myxomatous is sarcomatous, 
 and the growth is called periductal sarcoma. 
 
 Symptoms and Clinical Course. — Usually occurring in young 
 unmarried women, these growths well deserve the name "chronic 
 mammary tumor" bestowed upon them by Sir Astley Cooper. They 
 present few^ symptom's other than the presence of a "lump in the 
 breast," which usually is discovered accidentally, and may be attril)- 
 uted to injury. When of long duration a visible swelling may exist. 
 This swelling or lump is in the central portion of the gland, but not 
 close to tlie nipple. It feels hard, is well defined from the rest of the 
 gland, is not tender, and seldom is movable except in one mass with 
 the breast. Palpation of the breast with the flat hand, pressing it 
 against the chest, demonstrates the presence of an actual tumor; the 
 lump does not vanish as does that due to chronic mastitis, when this 
 mana?uvre is adopted. The overlying skin is not affected, nor are the 
 axillary uodes enlarged. The tumor grows very slowly, and ma}' 
 remain for years in much the same condition. Occasionally, however, 
 rapid growth occurs; this, of course, is a bad omen. But in most 
 cases the prognosis is absolutely good. 
 
 Treatment. — The tumor should be removed. It is encapsulated, 
 and by exposing the posterior surface of the mammary gland, as 
 described below, the growth can be enucleated, the breast replaced, 
 and no visible scar wdll remain. This method of plastic resection of 
 the breast, introduced in 1882 by T. Gaillard Thomas, has been re- 
 vivified by J. Collins Warren. It is thus performed: An incision 
 is made from the anterior axillary fold inward in the submammary 
 crease, as far as the inner lower quadrant of the breast. This incision 
 is deepened to expose the pfictoralis major, and the mammary gland 
 is dissected from its surface and is thrown upward on the patient's 
 chest. As the main blood-supply of the gland enters it from its 
 superficial surface, near its upper border, no fear of sloughing need 
 be felt. The posterior surface of the gland being thus brought to 
 vieW', the region of the tumor is exposed by an incision radiating from 
 the centre; the tumor is enucleated, and the cavity is obliterated by 
 
712 SURGERY OF THE BREAST 
 
 catgut sutures, thus restoring the contour of tlie breast. This is 
 then replaced on the pectoral muscle, and the deep layer of the 
 superficial fascia carefully sutured, so as to retain the breast in place; 
 and tlic >kin i> clo-cd w ith ])ruvision for drainage. 
 
 2. Cystadenomatous Tumors. — These seem to represent a later 
 development of the fibro-adenomatous tumors just described; and 
 as nearly all growths in the breast at the present day are removed 
 soon after their presence is discovered, it results that cystadenomatous 
 tumors are much more rare now than fifty or one hundred years ago. 
 At that time the curious combination of fibrous and epithelial pro- 
 liferation, resulting in solid (perhaps sarcomatous) tumors filled 
 with cysts, was productive of great confusion as regards nomenclature. 
 This class of tumor was described by Astley Cooper as hydatid disease 
 of the breast; Brodie called it sero-cystic sarcoma; Paget named them 
 proliferous mammary cysts; and Johannes Miiller used- the term 
 cysto-sarcoma phyllodes, both the latter observers laying special stress 
 on the occurrence of intracystic papillary out-gro^\i:hs To the present 
 day the French call it adeno-sarcoma. 
 
 The grovslh consists, in fact, of a cystic tumor, with a more or 
 less abundant fibrous stroma — a fibrocysiadenoma. The cysts are 
 of various sizes, usually some of them quite large. Their lining 
 membrane may be quite smooth, as if from pressure atrophy. Almost 
 invariably from one or more areas of the cyst wall, papillomatous 
 growths project — papillary cystadenoma. These intracystic growths 
 have a solid core of fibrous tissue, and they may completely fill the 
 cyst and even cause its distention. It seems as if the proliferation of 
 the stroma had converted the semi-circular chinks or slits of the 
 intracanalicular fibroma into actual cysts formed by the pressure of 
 papillary out -growths into the duct lumen. This impression is con- 
 firmed by the fact that the papillomas are covered with cells which 
 present the characteristics of ductal rather than of acinal epithelium. 
 The small amount of fluid which the cysts contain may be colorless, 
 slightly tinged with yellow or green, but usually is brownish or hem- 
 orrhagic in nature. 
 
 Symptoms and Clinical Course. — These tumors occur in older women 
 than do the fibro-adenomatous gro"uths. The average age in Warren's 
 patients was fifty-two years. Indeed, in most cases where cysts 
 are found in the mammary gland it is an indication that this organ 
 has reached its full maturity before the tumor began to grow. Cyst- 
 adenoma grows more rapidly than the solid benign tumors, and if 
 not removed, may reach a large size. The growth is situated in the 
 central part of the breast, beneath the nipple or areola, and at first 
 presents much the same features as the fibro-adenoma. In the course 
 of a few years, however, the presence of cj^sts usually may be sus- 
 pected from the lobulated nature of the tumor, and sometimes from 
 distinct fluctuation. But the latter rarely occurs, since the cysts 
 are apt to be filled with the papillary out-growths, which give them 
 a solid feel. The overlying skin is not altered, the axillary nodes 
 
SARCOMA 713 
 
 arc not enlar<;e(l, and seldom is the f^eiu'ral health aH'eeted. Very 
 often there is a hloody (hseharj^e from the nipple. In \ery advanced 
 cases the skin overix in<f one of the cysts may become thinned, and a 
 seinitranslucent appearance may be present. The l)reast may be 
 covered with a network of distended veins. Finally, as in the most 
 advanced staji;es of cystadenomatosis (p. 707) i)erforation of the skin 
 may occur, with the protrusion of the intracystic papillomas as a 
 fungus growth, .it any .stage of the disease maliynant changes may 
 occur. These may develop in the epithelial elements (carcinoma), 
 or rarely in the stroma (sarcoma.) 
 
 Diagnosis. — The diagnosis must be made from fibro-adenoma, 
 and from cystadenomatosis. From the former, cystadenoma usually 
 may be distinguished by the greater age of the patient, by the less 
 dense feel and less definite outline which the growth presents; as 
 well as by^ its more rapid enlargement and its eventually cystic char- 
 acter. From cystadenomatosis of the breast the distinction is difficult 
 only in the later stages, when the primarily local tumor (cystadenoma) 
 has grown so large as to occupy nearly the entire area of the mammary 
 gland. 
 
 Treatment. — Ablation of the breast, pectoral muscles, and axillary 
 lymphatics, as for carcinoma, is the safest treatment in patients 
 over thirty-eight or forty years of age. In younger patients, in 
 whom malignant changes are less likely, amputation of the breast 
 is sufficient. 
 
 Other benign tumors occur in the breast, but are extremely rare, 
 and present only pathological interest. A pure adenoma has been 
 described by S. W. Gross (1880) and by Rodman: it is a soft, suc- 
 culent, nodular, rather rapidly growing tumor, not very well encap- 
 sulated, and affecting young women. Lipoma may occur in the 
 interlobular tissues of the mammary gland, in the subcutaneous fat 
 overlj'ing it, or in the submammary tissues. Cases of angeioma 
 and endothelioma have also been recorded. Enchondroma is another 
 rare growth, de\eloping here, as in the salivary glands, in the form 
 of a "mixed tumor," with areas of cartilage and calcareous matter. 
 The diagnosis of these rare growths sometimes is not made until 
 after removal, which is the proper treatmejit. 
 
 Malignant Tumors of the Breast. — The general character of malignant 
 as distinguished from l)enign tumors was indicated in Chapter IV, 
 and it is not necessary to repeat tliis discussion here. It is enough 
 to say that over 70 per cent, of tumors of the breast are malignant, 
 and that in women approaching or past the menopause every tumor 
 should be regarded as malignant, and should be treated accordingly. 
 
 Sarcoma. — Sarcoma is very rare. It occurs in less than 3 per cent. 
 of cases of mammary neoplasm. Reference was made at (p. 711) 
 to a form of periductal sarcoma, which is classed among the benign 
 tumors. This forms about 80 per cent, of the cases of sarcoma of the 
 breast on record, a fact which emphasizes the exceeding rarity of 
 true mammary sarcoma. This truly malignant form of sarcoma which 
 
714 
 
 SURGERY OF THE BREAST 
 
 forms only 20 per cent, of the recorded cases of mammary sarcoma, 
 is of the spindle- or round-celled type, and epithelial proliferation is 
 scanty or absent. The tumor affects women at any age, probably 
 most often those between forty and fifty years. At first it is a well 
 defined, small, indolent mass, which may cause no symptoms for 
 years. Eventually, however, rapid growth sets in, the timior breaks 
 through its imperfect capsule, infiltrates the mammary gland, causes 
 distention, redness, and sloughing of the overlying skin, and in a few 
 months or even weeks there is a protruding, fungus, bleeding mass 
 (fungus hematodes). The diagnosis is difficult in the early stages; 
 when seen at this time the growth may be mistaken for a benign 
 tumor. Treatment consists in early amputation of the breast; the 
 axillary lymphatics very rarely are involved, but in patients past 
 thirty-eight or forty years it is a wise i)recaution to substitute ablation 
 for amputation, as in cases of carcinoma. 
 
 Carcinoma. — Carcinoma is the most frequent affection of the 
 breast. Only about 1 per cent, of cases occur in the male breast 
 
 (Fig. 789). Most tumors of 
 the breast in women over forty 
 years of age are carcinomatous, 
 but the disease is not at all 
 infrequent at an earlier age. 
 The older the patient, the 
 more apt is a tumor to be 
 carcinomatous. The left and 
 right breasts are affected with 
 al)out equal frequency. Very 
 rarely are both breasts simulta- 
 neously attacked (in about 1 per 
 cent, of cases), l)ut the disease 
 may spread from one gland to 
 the other through the lymph- 
 atics (Fig. 740). Heredity has 
 little influence in the clinical 
 etiology of the affection, nor 
 has race. It is more frequent 
 in married than unmarried 
 women, particularly in those 
 The influence of direct trauma 
 
 '.). -Scii'i licus cari'iiiiiiiKi (if uiai 
 breast, am; fifty-iiiiit' years; duration three 
 years; rapid growth for one year. Axillary 
 nodes palpable. (Dr. J. P. Hutchinson's 
 case.) Pennsylvania Hospital. 
 
 who have borne and suckled children, 
 seldom is noted (Plate V). 
 
 Pathology. — A tumor of the mammary gland may begin as a car- 
 cinoma, or carcinoma may develop in a previously existing benign 
 tumor. The latter is much the rarer; it oftenest succeeds the change 
 described as abnormal involution of the breast (p. 707) and assumes 
 the type of adeno-carcinoma, or "duct cancer" (p. 125). In 
 this form the tumor lies near or beneath the nipple, which is not 
 retracted; the growth is soft, shows little tendency to infiltrate, but 
 early breaks through the skin, and appears as an ulcer without the 
 
PLA'FE V 
 
 Scirrhous Carcinoma of Breast. 
 
 Specimen (half natural size) from excision of right breast for carcinoma. Aged 45 years; duration 
 2 5 years, ulcerated 6 months. Tumor developed a few months after direct trauma. Note the "rose 
 ulcer" in the uiipor outer quadrant, measuring 3x2 inches and covered with adherent gray-green slough; 
 beneath this was a hard tumor the size of a goose egg (Plate VI), not attached to chest wall. Visible 
 mass in axilla. Tumor, i^ectoral muscles, and axillary structures removed in one mass. Episcopal Hospital. 
 
,SClliUlli>VS CARCINOMA 
 
 715 
 
 liard and tliickt'iu'd inaririns so characteristic of the commoner types 
 of carcinoma, and ha\ in<,' its surface not depressed but rather ele- 
 vated above the surrounding^ skin. Rarely does this growth long pre- 
 serve the relatively benign character of an adeno-carcinoma; it soon 
 lirt)liferates in an atypical manner like the solid-celled carcinoma. 
 The latter, which is the usual form of carcinoma seen in the breast, 
 arises in an atypical proliferation of the ei)ithclial cells lining the 
 acini of the gland, and thus is distinguished from the rarer and less 
 malignant duct-cancer by the term acinous carcinoma. 
 
 Fig 740.— Carcinoma simplex of both breasts, age sixty-six years. Growth in left 
 breast for five years, ulcerated five months; large sloughmg ulcer; axillary nodes palpable. 
 Growth in right breast for two years: skin red and adherent; nippe retracted ; axillary 
 nodes palpable. Palliative amputation of both breasts in October, 1909 with prolonged 
 after-treatment by x-rays. (Dr. Thos. S. Stewart.) In September 1911, a metastatic 
 growth appeared in right thigh. In August, 1913, mediastinal and pulmonary metastases 
 but no local recurrence. In January, 1914, feeble, but little discomfort. Episcopal 
 Hospital. 
 
 The microscopical features of adeno-carcinoma and solid-celled 
 carcinoma were considered at (p. 125). Clinically, the usual 
 type of mammary carcinoma, that classed as solid-celled, is en- 
 countered in tlu-ee varieties dependent upon the relative amount 
 of stroma present: Scirrhous Carcinoma, in which stroma is very 
 abundant and cellular elements scanty; Carcinoma Simplex, in which 
 stroma and epithelial elements exist in equal amount; and Medullary 
 Carcinoma, in which the epithelial elements are very abundant and 
 the stroma is scanty. The clinical features of these three forms may 
 now be briefly considered. 
 
 Scirrhous Carcinoma, or simply Scirrhus, is the most frequent 
 form of mammary cancer. Owing to the abundance of the stroma 
 the tumor is quite hard; it seems as if the surrounding tissues were 
 endeavoring to stifle the growth of the epithelial elements. On 
 section the tumor is found to be absolutely continuous with the 
 surrounding tissues; there is not the slightest indication of a capsule; 
 it is impossible to remove the tumor from the gland. It is hard. 
 
710 
 
 SURGERY OF THE BREAST 
 
 and creaks when cut by the knife. Usually both the cut surfaces are 
 found to be concave; it is as if the tumor was too small for the tissues 
 in which it grew, and tended to contract further at the first opportu- 
 nity. The surface of the section often has been likened to that of an 
 unripe pear: it is pale and shiny, grayish white at first, but becomes 
 pinkish on exposure to the air. Usually there are yellow dots scat- 
 tered over the surface of the tumor; these are either spots of fatty 
 degeneration, or areas of fatty tissues not yet strangulated by the 
 fibrous stroma. On scraping the section with the knife, "cancer- 
 juice" is produced; but this is no longer regarded as particularly 
 characteristic of carcinoma. 
 
 Symptoms and Clinical Course. — The patient finds a lump in her 
 breast, but rarely are there any subjective symptoms. There may 
 be occasional lancinating pains, but the tumor is not tender, a fact 
 which distinguishes it from all inflammatory swellings. This lump 
 
 in most cases lies in the per- 
 iphery of the mammary gland, 
 not near the nipple; and is 
 found oftenest in the upper 
 outer quadrant. It is hard, 
 but not definitely outlined, 
 when felt between the thumb 
 and fingers; and it is still pal- 
 pable as a dense nodule when 
 the breast is pressed by the 
 palm of the hand flat against 
 the patient's chest. This dis- 
 tinguishes it from non-neoplas- 
 tic thickenings of the mammary 
 gland. Owing to the abundance 
 of the fibrous stroma and its 
 tendency to contract, the size 
 of the breast usually is dimin- 
 ished in cases of scirrhus; when 
 this contraction is extreme, the condition is named atrophic or 
 withering scirrhus (Fig. 741). An early and valuable sign due to 
 this contracting tendency has been pointed out by Halsted: this 
 is limitatio7i of the excursions on the chest wall of the affected mamma 
 as compared with the normal gland. If the breast is pulled from side 
 to side, and up and down, even in the case of a small, deeply seated, 
 and almost impalpable nodule, it will be found that the excursions 
 of the affected breast are diminished, especially in a direction away 
 from the axilla. The cancer cells extend along planes of fascia in all 
 directions, and the abundant fibrous stroma follows them up, as if 
 in the endeavor to strangle them by its contraction. This extension 
 and subsequent contraction limits the excursions of the breast, pulls 
 the nipple down into the gland {retraction of the nipple), and, tlirough 
 the ligamenta suspensoria of Sir Astley Cooper, causes the typical 
 
 Fig. 741. — Atrophic or withering scirrhus of 
 breast. Age seventy-five years; growth 
 noticed only a little over a year ago; ulcer- 
 ated for six months. Has had no treatment, 
 and the growth is now adherent to the ribs 
 and inoperable. Episcopal Hospital. 
 
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SCIRRHOUS CARCIXOMA 
 
 111 
 
 (liiiipling of tlie overlying skin resembling an orange or pig skin. 
 Tims qnite early the overlying skin beeomes fixed to the growth, 
 and the growth beeomes fixed to the pectoral fascia. The axillary 
 lyinphatirs are not j)alpably enlarged early in the disease, bnt they 
 are microscopically invaded long before they become palpable. The 
 diagnosis shonld be made before this complication or ulceration of the 
 skin tlevelops. llccraiion is a late stage of the disease, usually not 
 appearing for one or two years after the development of the tumor. 
 In some cases (atrophic scirrhus) ulceration may never occur. When 
 it develops it is due to gradual in\'asion of the skin by the cancerous 
 growth; a small ulcer first ai)pears, and this gradually increases in 
 size. The scirrhous ulcer is quite typical: it is more or less circular 
 in outline, fixed to the chest wall, red, dry, and quite dense; colloqui- 
 ally it is known as the ^' rose ulcer" (Fig. 742). Occasionally as a 
 
 Fig. 742. — Scirrhous carcinoma of breast showing typical "rose ulcer." Age sixty- 
 eight years; duration three years; ulcerated six months. Has had no treatment, and 
 growth is now adherent to ribs and inoperable. Two years and six months later, there 
 was a large stinking ulcer, patient was extremely emaciated, hardly able to stand, and 
 suffered dreadful pain. Episcopal Hospital. 
 
 primary growth, but more often as a recurrence after operation, 
 carcinoma grows either in many apparently isolated spots over the 
 chest wall, or widely diffused in the skin; this is known as "squirrhe 
 en cuirasse," as if the patient was covered with a "coat of mail" 
 composed of carcinomatous nodules (Fig. 744). 
 
 Prognosis and Treatment. — Owing to the slow growth and few 
 subjective symptoms produced by the tumor, the patient often 
 does not seek surgical advice until fixation and perhaps ulceration 
 have occurred. The average duration of life in untreated cases of 
 scirrhus is from two and a half to three years. The more atrophic 
 the type, the longer will death be delayed; sometimes the patient 
 drags out a painful existence for twenty years. If radical operation 
 is done before fixation of the tumor, so that it is possible to remove 
 all of the disease, freedom from recurrence for three years or more 
 (which is classed as "ultimate cure") will result in from 50 to 70 
 
718 SURaEKY OF THE BREAST 
 
 per cent, of cases so treated. The reasons why operation should be 
 urged, even with no better prospects, are stated at p. 725; and the 
 
 I" ^1'^' — ^'^rcinoma simplex of left breast. Age forty-four j-ears; duration seven 
 months from recurring trauma from work in mill. Note pig-skin dimpling, retraction 
 of nipple, breast standmg out from thorax; emaciated face, and anxious expression. 
 (See Fig. 744.) Episcopal Hospital. 
 
 Fiu. 744. — Recurrent carcinoma of breast one year aftf r oxci^ion. Note cancer en 
 cuirasse, fatter face and less anxious expression since being under hospital care; edema 
 of left arm; involvement of right axilla. Two and a half years after operation, condition 
 no worse, growth seemingly held in check by constant i-ray treatments. (Dr. Thos. S. 
 Stewart.) Xo pain, less edema of arm. Episcopal Hospital. 
 
 question of operabiHty is discussed in the same place. In inoperable 
 cases palliative treatment, as outlined in Chapter IX, is indicated. 
 
I'AdKT'S DISKASh- OF Tlll<: MI'I'IJ': 719 
 
 Carcinoma Simplex or Acute Scirrhus is an iiitcrnu'dicite form between 
 the scirrhous and incihiMary t\|)('s. The tumor causes increase in 
 the si/e of the hreast, and ^rows rai)idl\'; the axilhiry lymphatics 
 are i)alj)al)I\' in\ oh'cd (juite early in the disease, and all local symptoms 
 (limitation of excursion of tlie hreast, retraction of the nipple, orange 
 skin dimpliufi) occur sooner than in the scirrhous form fFig. 748). 
 Ulceration also develops earlier and the ulcer is deeper hut is not 
 fixed to the chest wall; its surface is covered with slouj^hs, there is 
 more dischar<ie, and hemorrhages may occur (Fig. 74()j. 
 
 Prognosis inul Treatment. — On account of the more rapid growth 
 of the tumor, tiie patient usually seeks advice sooner than in the 
 scirrhous form, and therefore radical treatment more often can be 
 undertaken with a hope of cure. 
 
 Medullary Carcinoma is much rarer than either scirrhus or carcinoma 
 simi)lex. The tumor occurs in younger women, and is of extremely 
 raj^id growth, often simulating a phlegmonous process. The over- 
 lying skin is red and tense; the breast is covered with dilated veins, 
 and feels hot on ])alpation; soft areas resembling suppurating cysts 
 or abscesses may be felt; and in the course of a few weeks the whole 
 surface of the tumor breaks down, and a foul, sloughing mass pro- 
 trudes. Hemorrhages are frequent, and large clots may cover the 
 surfaces of the mass (Fungus Hematodes). On section the tumor 
 often resembles softened brain matter, whence it sometimes is called 
 encephaJoid; it is friable and pulpy. An extreme type of medullary 
 carcinoma, with most alarmingly rapid growth, is described as car- 
 cinoniafoiis mastitis. This often involves both breasts. 
 
 Prognosis and Treatment. — Death usually occurs within a few 
 months, even early radical operation proving ineffectual in preventing 
 recurrence. Those tumors developing during pregnancy are the most 
 malignant of all. 
 
 Paget's Disease of the Nipple. — This was described by Sir James 
 Paget, in 1874, as a form of dermatitis or eczema predisposing to 
 carcinoma of the breast. It is a rare disease, and while almost all 
 ca.ses occur in the nipj)le of the female breast, a few have been recorded 
 as occurring in other parts of the body. The exact nature of the 
 affection is still disputed by pathologists. Most authorities consider 
 it carcinomatous from the beginning, but its point of origin is un- 
 determined. Some hold that it arises in the galactophorous ducts 
 and invades the skin secondarily; others believe that it originates in 
 the epidermis and invades the ducts secondarily. Microscopically 
 the characteristic feature is the presence of large transparent multi- 
 nucleated cells ("Paget cells") in the deeper layers of the epidermis. 
 Clinically the disease aft'ects women of the cancer age; it begins as a 
 scaly affection of the nipple, typically eczematous in nature but totally 
 uninfluenced by local remedies usually effectual in relieving eczema 
 in other parts of the body. As the disease progresses, the areola is 
 involved, and the erosion or excoriation continues to spread super- 
 ficially for months before the glandular tissue is noticeably affected. 
 
"20 
 
 SURGERY OF THE BREAST 
 
 The area usually is moist, but some psoriasis-like cases have been 
 reported. The subjective symptoms are itching, tingling, and burning; 
 but the general health is not impaired. 
 
 Treatment. — Treatment consists in amputation of the breast as 
 soon as the disease is recognized; if the disease is extensive or of long 
 duration, it is safer to do a radical operation as for carcinoma. 
 
 Cancer Cyst. — This is the rarest form in which malignant disease 
 of the breast occurs. It has been studied by Bloodgood (1907). 
 Usually occurring as a single cyst, it grows slowly, and presents 
 few clinical signs of malignancy. Exploratory operation being under- 
 taken, the cyst is found to contain bloody fluid, and there is no intra- 
 cystic papillomatous out-growth to account for this fact; but usually 
 an indurated or ulcerated area is found in the cyst wall. Any cyst 
 which is opened at operation, and is found to contain hemorrhagic 
 fluid, should be looked upon as carcinomatous unless there is an 
 intracystic papilloma to account for the blood. 
 
 Treatment consists in radical operation as for other forms of car- 
 cinoma. 
 
 Extension of Mammary Carcinoma. — Local extension occurs especially 
 to the o\-erlying >kin, to all portions of the mammary gland and its 
 
 ramifications, and to the sur- 
 rounding adipose tissue. The 
 deep fascia overlying the pec- 
 toral muscles and as far down 
 as the epigastrium is widely 
 infiltrated, and early invasion 
 of the pectoralis major muscle 
 may occur, as demonstrated by 
 Heidenhain (1S89). 
 
 Lymphatic extensions are di- 
 rectly continuous with the main 
 growth by fine columns of cancer 
 cells. As the primary tumor in 
 most cases is in the upper outer 
 quadrant it is the axillary lym- 
 phatics that are first invaded as 
 a rule, and this invasion occurs 
 long before the nodules are pal- 
 pable. In most cases the nodes 
 which first become palpable are 
 those on the side of the thorax, about midway between the axillary 
 folds. Let the patient's arm hang by her side, so as to relax the 
 axillary fascia, and then palpate gently and attentively in this region. 
 But in the case of a growth in the extreme upper and outer part of 
 the gland, early extension may occur to the nodes highest in the 
 axilla, and these rarely can be palpated. In time all the axillary 
 lymphatics are involved, and even the supraclavicular nodes may 
 become enlarged. In advanced cases lymphedema of the arm results 
 
 ■ 
 
 
 
 ■ 
 
 ^^^ 
 
 / 
 
 € 
 
 ^H 
 
 
 BES^"* ■ 
 
 
 1 
 
 1 
 
 
 
 u 
 
 
 
 Fig. 745. — L^niijhatics of the breast and 
 axilla, involved in mamniarj- carcinoma. 
 Episcopal Hospital. 
 
RADICAL OPERATION FOR MAMMARY CARCINOMA 721 
 
 from the axillary lyinpliatic" oljstruction; venous obstruction may also 
 contribute to the edema; and pain from compression of the axillary 
 nerves may be a very distressitiff symjitom. Lymphatic extension 
 may also occur to the mediastiinmi, especially if the tumor grows 
 in one of the inner quadrants of the breast; or extension may occur 
 across the middle line of the body to the other breast, or even to 
 the other axilla. Both breasts and both axillae always should be 
 examined attentively. Finally reference must be made again to 
 cancer en ciiira.s.sr, due to widespread carcinomatous lymphangeitis 
 of the skin. 
 
 Distant metastases by way of the blood-stream are denied by modern 
 pathologists. Cancer cells in the blood excite thrombosis, and the 
 thrombus as it organizes usually destroys or renders them harmless 
 (Handley). Ilandley has also indicated that bone lesions (confined 
 to the bones of the trunk, the proximal ends of the limbs, and the 
 skull) are in direct continuity with the main growth; their site often 
 is suggested by the presence of subcutaneous nodules over the affected 
 bone, even before bone pains, or pathological fracture demonstrate 
 their existence. In cases of scirrhus this sad event occasionally 
 occurs before the local tumor is noted; and it is a rule always to 
 consider the possibility of already present metastases before operating 
 on a case of scirrhus, and always to inquire into the condition of the 
 mammary gland in the case of obscure malignant growths in the 
 bones or viscera. 
 
 Radical Operation for Mammary Carcinoma. — Ablation of the Breast. — 
 The general principles on which a radical operation for malignant 
 disease is based were discussed- in Chapter IV (p. 132). The develop- 
 ment of the technique of the modern operation for carcinoma of the 
 breast is due largely to the teaching of C. H. ]\Ioore, Volkmann, 
 Heidenhain, Stiles, Halsted, and Ilandley. Moore (1867) was one 
 of the earliest to discard the theory of a cancerous diathesis, and to 
 look upon it as a disease of purely local origin; in consequence he 
 urged wide excision of the breast and all involved structures (pectoral 
 fascia and muscle and enlarged lymphatics) in one mass. Volkmann 
 (1875) always excised the pectoral fascia and emphasized the necessity 
 of removing the surface of the pectoral muscles when diseased, and 
 established the "three year limit," all patients free from recurrence 
 after this interval being reckoned as "cures." Though recurrences 
 (or perhaps new carcinomas) may grow after intervals of ten and 
 even twenty or more years, it is found by the best operators today 
 that recurrence after a free interval of three years occurs in only 
 about 20 per cent, of patients. Heidenhain (1889) urged removal 
 of the surface of the pectoral is major muscle in all cases, even when 
 not visibly diseased, as on microscopic examination he found it always 
 invaded by cancer cells. Stiles (1892) called renewed attention to 
 the importance of wide local excision, showing the great area over 
 which the mammary gland was spread out — sending processes to the 
 clavicle above, to the axilla laterally, and well below the lower border 
 46 
 
722 
 
 SURGERY OF THE BREAST 
 
 of the pectoralis major, on to the serratus magnus, rectus, and external 
 oblique muscles. Halsted (1894) introduced removal of the pectoralis 
 major as a measure of routine, to facilitate clearing the axilla, in 
 every case, whether the axilla was manifestly diseased or not; and he 
 also insisted that the supraclavicular lymph nodes should be excised, 
 and that the entire diseased tissue should be removed in one piece. 
 Willy Meyer in the same year urged removal of the pectoralis minor 
 in every case, and renewed the advice of Gerster (1885), who had 
 advocated commencing the operation by the axillary dissection, 
 which was left by others for the last step, and usually was under- 
 taken only after the main tumor mass had been cut away. Finally-, 
 Handley, in his Astley Cooper prize essay (1905), demonstrated 
 anew the importance of the deep fascia as the main highway by which 
 the carcinoma cells spread in all directions from the common centre 
 of disease, and has shown the necessity of removing it in a wide 
 circle on all sides of the growth, which should be taken as a centre, 
 the circumference to which excision should extend having as radius 
 the distance from the tumor to the clavicle. This excision extends 
 laterally to the latissimus dorsi, medially well beyond the middle 
 line, and inferiorly at least two inches below the ensiform process.^ 
 
 The operation thus comprises removal of a very wide area of skin, 
 the mammary gland with surrounding fat, the deep fascia, both 
 
 pectoral muscles, and axillary 
 lymi)hatics, in one viass. If this 
 diseased mass is cut into at any 
 point the contained cancer cells 
 will be given a chance to escape 
 into the surrounding healthy tis- 
 sues, and recurrence will be very 
 apt to follow. For the same 
 reason all rough handling and tear- 
 ing the tissues apart by blunt 
 dissection should be avoided. 
 
 Skin Incision. — So long as this 
 removes a sufficient area of skin, 
 its particular form is immaterial. 
 A wound which cannot be closed 
 completely is less likely to be the 
 seat of recurrence than one which 
 can, because there is less likeli- 
 hood of diseased tissue remaining. 
 I prefer Jabez N. Jackson's (Fig. 
 746) incision (190(3) for early cases 
 with little apparent involvement of the skin. For the average case 
 Rodman's incision is as good as any (Fig. 747). Only a portion of the 
 incision is made at first, sufficient for the dissection of the axilla, 
 which should constitute the first step in the operation. To postpone 
 this to the last, as in Halsted's method, leaves the entire thoracic 
 
 Fig. 746. — Jackson's incision for fani- 
 noma of the breast, suitable for early 
 cases. The rectangular flap is turned down- 
 ward and the axillary flap upward in 
 closing the wound. Episcopal Hospital. 
 
RADICAL (H'Kh'A'I'IOX FOh' M A M M A h'Y CARCINOMA 
 
 '28 
 
 wound rx])ose(l (lurinjij the most tedious part of the oiH'ration; whereas, 
 it' the axilhi is cleared first (and this may re((uire two liours or more 
 in (hfhcult eases) the remainder of tiie operation may he eoinpleted 
 in ahont fifteen minutes. Moreover, the hhxxl-supply is eontrolled 
 nnieh more (>ii"eetively if each branch going to the tumor mass is 
 secured at its origin. 
 
 Tlie i)eetorahs major nuiscle is exposed first, its upi)er border 
 identified, chimping or protecting the cejjhalic vein. A finger is 
 tlien passed beneath tiie muscle, 
 and it is di\ided close to its 
 humeral attachment. The cla- 
 \icular fibres of the jjectoralis 
 major are next cut close to the 
 bone. This exposes the pector- 
 alis minor, which is similarly 
 divided close to the coracoid 
 process, and the axilla is fully 
 exposed. If there are palpably 
 enlarged lymph nodes at the apex 
 of the axilla, the skin incision 
 should })e extended upward 
 across the clavicle, and the 
 supracla\'icular nodes explored. 
 If enlarged they should be re- 
 moved. I'nfortunately it is not 
 feasible to remove them in one 
 mass with the axillary lymph- 
 atics, and they must be excised 
 separately. Then the axilla is 
 cleared from above downward, 
 working along the axillary vessels 
 to the lower border of the latis- 
 
 simus dorsi. Arterial and venous branches are clamped and cut close 
 to the main trunks. Whenever the supply of hemostats is exhausted, 
 all clamped points should be ligated, thus releasing the hemostats for 
 future use. The main nerve trunks are carefully preserved, as is the 
 median (long) subscapular nerve which supplies the latissimus dorsi; 
 injury to this will affect the usefulness of the arm. Sensory nerves 
 may be cut without compunction. When the vessels once have been 
 dissected free the operation may proceed with greater rapidity. The 
 entire axillary contents are turned toward the chest, and the lateral 
 thoracic wall, from behind forward, is denuded of fascia; here the long 
 thoracic ne^^'e (external respiratory) should be looked for and pre- 
 served. The axillary wound is then filled with gauze. 
 
 The skin incisions are gradually extended to outline the breast, 
 and are extensively undermined, on all sides, leaving attached to 
 them only enough superficial fat to prevent sloughing. The axillary 
 contents and pectoral muscles are then turned toward the median 
 
 Fig. 747. — Rodman's incision for carci- 
 noma of the breast, suitable for most 
 cases. The triangular flap below the 
 clavicle is pulled downward, and the under- 
 mined skin on the lateral surface of the 
 thorax is pulled upward, the wound being 
 sutured in the form of the letter T, the 
 long limb lying in the long axis of the 
 breast. Episcopal Hospital. 
 
724 
 
 SURGERY OF THE BREAST 
 
 line, and the dissection of the chest is continued from the lateral 
 wall to the sternum. Here the perforating branches of the intercostals 
 and internal mammary arteries will be encountered, and may cause 
 troublesome bleeding if allowed to retract below the intercostal 
 muscles before being clamped. The tumor mass now })eing free above, 
 the dissection is continued downward, removing the deep fascia over 
 the upper portir)n of the rectus muscle in the epigastric region. 
 
 Fig. 748. — Ablation of the breast: the pectoralis major has been cut near its humeral 
 insertion, and its clavicular fibres have been divided, exposing the pectoralis minor. 
 The entire skin incision (indicated in the drawing) is not made at one time, but only 
 as the operation proceeds. 
 
 The tumor being thus removed, a puncture for drainage is made 
 in the skin of the axilla, and a tube introduced. This is allowed to 
 remain four or five days. The skin is then sutured, closing the wound 
 as far as can be done without undue tension. The arm is dressed in 
 a fully abducted position; this permits more accurate apposition of 
 the skin to the axilla, prevents accumulation of wound discharges 
 here, and facilitates return of the function of the upper extremity. 
 When the skin is accurately adjusted to support the axillary struc- 
 tures, it is very seldom that disability follows from cicatricial con- 
 traction. Lymphedema may develop after the operation, especially 
 when a thorough removal of the axillary lymphatics has been accom- 
 plished. It may be treated by Plandley's operation (p. 270). Excel- 
 lent motion is retained by the arm in spite of removal of both pectoral 
 muscles, and the patient is little if at all inconvenienced by their loss. 
 Murphy retains them as pads to fill up the hollow of the axilla, and 
 removes the breast before beginning his axillary dissection. Few 
 or no surgeons any longer approve of this method of operating. 
 Tansini slides a musculo-cutaneous flap from the back across to the 
 thoracic wound, permitting of its complete closure in every case. 
 
 The immediate mortal if y of the extensive operation described above 
 is very low — not more than 1 per cent, in skilled hands. Deaths are 
 caused almost solely by visceral complications, such as pneumonia, 
 cardiac disease, or uremia. 
 
RADICAL OPERATION FOR MAMMARY CARCINOMA 725 
 
 Affrr-irfatmrnt.-W'hvn the iiu-ision cannot bo sntiircfl completely, 
 some surgeons prcl'(T to do skiii-^'riiftiii},^ at the <-oii(lusioii ot" the 
 operation; while others postpone this niitil ^frainilation has commenced. 
 Personally I believe it is better to do ni'ither, bnt to expose the frramj- 
 lating surface to the .r-ray at suitable intervals. If this treatment is 
 conducted by a skilled nintucnolo^ist, there seems nuich less tendency 
 to recurrence, and where inoperable recurrence takes ])lace this treat- 
 ment greatly relieves the pain, diminishes the discharge and fetor, 
 and keeps the })atients comfortable (Figs. 740 and 744). 
 
 Examination of the wound for recurrence should be insisted ujjon, 
 at first monthly; then every three or four months, until the three 
 year i)erio(l has elapsed. After this time the patient should rej)ort 
 to her surgeon at least once a year, or immediately if any sj'mptoms 
 arise. 
 
 End RrsuJts of tlir RadicaJ Operation for ('(ircinonia of the Breast. — 
 If the oi)eration is done in favorable cases (before there is ])alpal)le 
 axillary involvement and before the tumor is fixed or the overlying 
 skin ulcerated), about 70 per cent, of patients will be "cured" in 
 Volkmann's sense; that is, they will remain free of recurrence for a 
 period of three years. And of these clinical "cures," only about one- 
 fifth will have a recurrence at a later date. If axillary invasion has 
 occurred before the operation is done, about 25 per cent, of patients 
 will be in good health after three years. These figures are conserva- 
 tive, as better results are reported by those who do most of these 
 operations. 
 
 But the advantages of the operation are great even if recurrence 
 or metastasis -eventually occurs. At the very worst, the patient 
 will enjoy a number of months, perhaps several years, of good health, 
 and will have hope of ultimate cure. Even if recurrence takes place 
 a cure may still be possible by aid of a second or third operation. 
 Finally, if metastasis occurs, and death results from this cause, it 
 will be a very much less painful death than that from local recurrence, 
 and the operation at least will have prolonged life and afforded an 
 interval of comfort and of hope. 
 
 Inoperable Cases. — Usually no operation should be undertaken 
 in cases in which it is manifestly impossible to remove all of the 
 disease. In most patients wdth the supraclavicular nodes palpably 
 enlarged, no operation, however radical, wdll effect a cure; but if 
 the tumor is not otherwise inoperable, the radical operation may be 
 done, these nodes being removed at a second operation ten days or 
 two weeks later. Only if they are very slightly involved is it safe 
 to prolong the original operation for their immediate removal. 
 
 Recurrences are to be treated on the same principles as the primary 
 growth. Even fixation to the chest wall does not necessarily contra- 
 indicate excision; the portions of ribs invaded may be removed. 
 
 Palliative operations sometimes are done in inoperable cases. Very 
 occasionally mere " ampidation" of the breast (p. 710), to remove 
 a sloughing ulcer, followed by x-ray treatment, will promote the 
 
■2() 
 
 SURGEJiY OF THE CHEST WALL 
 
 patient's comfort and prolong life even when cure is out of the question 
 (Fig. 740). Cauterization with the actual cautery, or with chemicals, 
 such as chloride of zinc solution (5 per cent.), sometimes will relieve 
 discomfort by sterilizing the surface of a sloughing growth. Double 
 oophorectomy, introduced by Beatson of Glasgow, in 1890, has been 
 employed in a number of advanced cases, and in some patients shrink- 
 age of the breast tumor and considerable relief has followed. Ampu- 
 tation at the shoulder-joint was employed by Esmarch (1883) as a 
 primary operation in one far advanced case, and has been practised 
 a number of times since in cases of recurrence; and even interscapulo- 
 thoracic amputation has been employed in cases of recurrence (Dent, 
 in 1897, and later by others). Others have employed rhizotomy 
 (p. 530), with marked relief of pain. 
 
 SURGERY OF THE CHEST WALL. 
 
 Congenital and Acquired Malformations. — These are of interest 
 from a diagnostic point of view, but little can be done in the way 
 of treatment. Birth i)ijuries occasionally result in deformities which 
 persist through adult life (Fig. 749), but seldom entail any disability. 
 The diagnosis is made from the history. Rachitic deformities, reference 
 
 Fig. 749. — Birth injury of thorax. 
 Orthopaedic Hospital. 
 
 Fig. 750. — Fuuiiel lireast iracliiticj. 
 Orthopaedic Hospital. 
 
 to which was made at p. 418, develop during infancy or early child- 
 hood, and are recognized by coincident symptoms of rachitis. The 
 most frequent deformities are the "rachitic rosary," Harrison's 
 groove, and pigeon breast; these seldom persist past the age of 
 puberty. Funnel breast, however, may last through life (Fig. 7oO). 
 
Injuries 
 
 Til 
 
 Some of these deforiuities iiuiy he improved by gymnastic exercises, 
 t)r by tlie use of ortliopedic apparatus, if treatment is begun in early 
 childhood; but the disability is so slight in adult life that no active 
 intcrfiTcnce is required. 
 
 Injuries. — The most frequent injury is fracture of the ribs. This 
 was considered at p. .S23. Simple contusions require no special 
 notice. Severe lacerated wounds, with compound fracture of the 
 ribs, usually are attended by visceral injuries (for which see p. 73.'-{). 
 They arc caused by crushing injuries, explosions, etc., and often are 
 
 fatal. If the patient survives, con- 
 valescence is prolonged, and severe 
 deformity may ensue (Fig. 751). 
 
 In some cases a phenomenon 
 known as traumatic asphyxia, or 
 stasis cyanosis, follow'S sudden vio- 
 lent compression of the chest (or 
 abdomen) of short duration. This 
 state is characterized by marked 
 cyanosis of the head, face, and 
 neck, usually sharply delimited a 
 
 Fig. 751. — Deformity of thorax 
 following injury by explosion in 
 coal mine. Episcopal Hospital. 
 
 Fig. 752. — Traumatic asphyxia; oxygen in- 
 halations. Death in twelve hours. Episcopal 
 Hospital. 
 
 short distance above the clavicle, apparently by the collar. The 
 patient looks as if he had been strangled (Fig. 752): the eyes are 
 bloodshot, and the eye-lids may become edematous; there may be 
 hemorrhages from the naso-pharynx or ears; convulsions or uncon- 
 sciousness may occur. In addition to shock, there is irregularity 
 or entire failure of respiration. The cyanosis, w^hich is petechial in 
 appearance, may be due to extravasation of blood (true traumatic 
 asphyxia) or to dilatation of the capillaries with blood stasis (stasis 
 cyanosis). It is difficult to differentiate the conditions, which, indeed, 
 often coexist. The mechanism by wdiich this state is produced is 
 believed to be sudden compression of the thorax with the glottis 
 closed, causing violent reflux of blood from the right heart. There 
 may be interstitial and subpleural hemorrhages in the lungs, with 
 
728 SURGERY OF THE CHEST WALL 
 
 interstitial emphysema; and in some cases cerebral congestion and 
 hemorrhages have been found postmortem. 
 
 Treatment. — Treatment comprises measures to o^'ercome shock, 
 with artificial respiration, and inhalations of oxygen. The pulmotor, 
 a mechanical device for artificial respiration employed in cases of 
 poisoning by illuminating gas, may be used with advantage. 
 
 Surgical Emphysema. — Surgical emphysema is a term used to 
 describe the esca])t' of air into the subcutaneous tissues. As previously 
 noted (p. 301) it may occur in the face in connection with fractures 
 of the nose, etc. The most usual form, however, is that due to thoracic 
 injury; and the air escapes across the pleura from the lungs which 
 have been punctured by a broken rib or ruptured by the compressing 
 force. If the emphysema appears first at the root of the neck, and 
 not at the site of injury, it is probable that the rupture of the lung 
 is entirely subpleural, and that the air has escaped into the loose 
 cellular tissues surrounding the bronchi, and eventually reaches the 
 neck by way of the mediastinum. This subcutaneous emphysema 
 may occur without any clinical evidence of severe intra-thoracic 
 injury, but as auscultation and percussion are much interfered with 
 by its development, it is probable that the deeper lesions often are 
 overlooked. Occasionally a wound of the pleura, without injury of 
 the lung, may cause the development of emphysema, the outside air 
 being sucked into the wound by the negative intra-thoracic pressure. 
 
 The air may spread far over the body, up to the scalp, dowTi to 
 the groin, and even out along the limbs; the eyes may be closed up, 
 and the patient may become so bloated that recognition will be 
 impossible. Subjective symptoms, except those due to visceral 
 lesions, are insignificant. Palpation of the areas affected produces 
 typical crackling; the skin feels as if floated up from the muscles or 
 bones by an effervescing liquid; the air may be driven from one 
 place to another by the fingers, and pitting on pressure is apparent. 
 The larger the source of supply, the more rapid will be the develop- 
 ment and spread of the emphysema. In some cases only a very 
 limited area is affected, and attentive examination is required to 
 detect it; in others the emphysematous area increases rapidly in size 
 as the patient is watched. 
 
 Treatment. — Mild cases require no treatment; but usually, whether 
 or not there is fracture of the ribs, the injured side of the thorax 
 should be strapped, as limitation of the respiratory excursions will 
 diminish the spread of the air. Where the emphysema is very marked, 
 it has been recommended that multiple pinictures be made with a 
 fine pointed bistoury, or tenotome, whereupon air will escape with 
 a hissing noise, and the swelling will partly subside. As a matter of 
 fact, if any treatment is necessary, it is much better to aspirate the 
 pneumothorax, since as long as this continues air will escape from it 
 into the subcutaneous tissues. The chief danger is infection of the 
 subcutaneous tissues, with widespread cellulitis. Apart from this and 
 visceral lesions, the prognosis is good. 
 
AXILLARY ABSCESS 
 
 r29 
 
 Axillary Abscess. Tins inn\- he .superficial or deep. Tlu; fcjrmcr, 
 wliicli i> more frt'(iiu'iit and loss serious, arises in connection with the 
 hair t'oUlck's or sehaceous <jhin<ls, as a furuncuh)sis; the process occurs 
 superficially to the axillary fascia. I'sually .suppuration starts in 
 several different points, but if incision is not made promptly these 
 may coalesce to form one abscess (Fig. To']). Trcaimeni consists in 
 incision and drainage. 
 
 Fig. 75.3. — Abscess superficial to deep 
 fascia of axilla. Episcopal Hospital. 
 
 Fig. 7.54. — ^Deep axillary abscess, 
 following lymphadenitis; duration six 
 weeks. Episcopal Hospital. 
 
 Deep or True Axillary Abscess arises in the tissues of the axilla 
 underneath the axillary fascia; it begins as lymphadenitis (Fig. 754), 
 and usually is due to a primary infection in the hand, or rarely in 
 the breast. Occasionally these deep axillary abscesses point through 
 the thin (cribriform) portions of the axillary fascia and present 
 beneath the skin. Rarely the pus may travel upward along the sheath 
 of the axillary vessels and point at the root of the neck. Owing to the 
 deep seat of the inflammation, and to the pus being covered by the 
 dense axillary fascia, distinct evidences of suppuration often are 
 absent. The surgeon should not wait for fluctuation, or even for 
 redness and edema of the overlying skin, or other classical signs of 
 abscess. The subjective symptoms, pain, tenderness, and loss of 
 function of the arm, are so severe as to suggest serious trouble, and 
 the constitutional evidences of infection may be marked. Therefore 
 no time should be lost in draining the axilla. Usually an anesthetic 
 is desirable. An incision is made from the outer border of the axilla 
 inward to the chest wall, midway between the anterior and posterior 
 axillary folds. After the skin is incised the knife should be kept 
 fairly close to the thorax, \yhen the axillary fascia has been incised, 
 if pus does not flow, further exploration should be conducted accord- 
 ing to Hilton's method (p. 51). The axilla is drained by a tube, and 
 the arm is carried in a sling. 
 
730 
 
 SURGERY OF THE CHEST WALL 
 
 Subpectoral Abscess. — This is an abscess between the pectoralis 
 major muscle and the pectoralis minor, or one beneath the latter 
 muscle, at the extreme apex of the axilla. Probably in most cases 
 it is caused by direct contusion or strain of the pectoral muscle, 
 producing a small hematoma which subsequently is infected through 
 the blood-stream. It may arise in suppuration of the subclavian 
 lymph nodes, which lie on the anterior surface of the pectoralis minor 
 or clavipectoral fascia. Sometimes this follows infected wounds of 
 the thumb or index finger or radial aspect of the forearm, since the 
 lymphatics from these regions may pass du-ectly to the.se nodes along 
 the cephalic vein; whereas the lymphatics from other regions of the 
 hand and forearm enter the axilla with the brachial vessels. Rarely a 
 subpectoral abscess is caused by caries of the ribs, or by bronchial 
 or pleural infection; in such cases the abscess often is chronic and is 
 due to tuberculosis ^Tig. 758 j. 
 
 Fig. 7.5.5. — -Right subpectoral a>>- Fig. 7.50. — Abscess in left supra.spinous 
 
 scess; duration three weeks. Xo fossa; duration one week; cause unknown. 
 
 cause discoverable. Episcopal Hos- Incision evacuated six to eight ounces of pus. 
 
 pital. Healed in six days. Episcopal Hospital. 
 
 Symptoms. — A subpectoral abscess forms a rounded, tender, painful 
 swelling below the inner part of the clavicle; it tends to point at the 
 lower border of the pectoralis major (Fig. 755 j, or rarely may burrow 
 through an intercostal space into the pleura. It is differentiated from 
 axillary abscess by its position nearer the median line of the body, 
 and by the relaxed condition of the axillary fascia and freedom of the 
 axilla; and from arthritis of the shoulder by the slight impairment 
 of the movements of the joint, which are quite free within a limited 
 range. I have seen the condition mistaken for tuberculosis of the 
 shoulder-joint. 
 
CMilES OF rilE h'lliS 
 
 7'M 
 
 Treatment. — Tlie abscess should he opened hy an iiicisi(jii aloiij^ 
 the lower l)order of the jjectorahs major, and shoiihl he drained with 
 a tiihc. Musser collected 2)^ cases with 1)-) deaths. 
 
 Subscapular Abscess. This is (piite rare. The pus hjrnis in the 
 space hetwen the serratus magnus and the posterior thoracic wall. 
 It cannot jioint anteriorly because of the attachment of the serratus 
 ma^nnis to the lateral asjjcct of the thorax; it cannot escape internally 
 because of the spinal connections of the scapula. The i)us, therefore, 
 spreads either upward, and points beneath the trapezius, which is 
 unusual; or downward to the angle of the scapula. 
 
 If the existence of this condition is remembered, the diagnosis 
 rarely will be difficult. The abscess should be opened at the lower 
 angle of the scapula, and drained. In some cases the body of the 
 bone may be trephined. 
 
 Suprascapular Abscess. — Suppuration in the supraspinous fossa is 
 another unusual condition (Fig. ToO). Unless the condition is borne 
 in mind, the swelling may be mistaken for a sarcoma. The onset 
 usually is subacute, and maj' follow the formation of a hematoma in 
 the supraspinatus muscle as the result of trauma; or the lesion may 
 be tuberculous and arise in the bone. The abscess should be opened 
 and drained, unless it is thought 
 to be tuberculous, when it should 
 be treated as a tuberculous ab- 
 scess elsewhere in the bo(h' (p. 
 483). 
 
 Caries of the Ribs. — This 
 usually is tul)erculous in nature. 
 It may be due to extension from 
 a focus in the vertebrae, or from 
 a tuberculous pleurisy; or the 
 disease may be primary in the 
 ribs. In the latter case devel- 
 opment of the afTection often 
 follows injury. Usually the 
 patients are adults, and there 
 often is pulmonary tuberculosis 
 or a tuberculous lesion in the 
 bones, joints, or lymph nodes. 
 Early formation of a cold ab- 
 scess occurs, and this presents 
 itself as a fusiform swelling 
 along the course of one or 
 more of the ribs. The ribs 
 from the third to the eighth are oftenest affected, near the chondral 
 or the vertebral joints. The disastrous results of spontaneous fistu- 
 lization and secondary infection are as prominent here as elsewhere 
 in the body where tuberculous disease is concerned. Interminable 
 suppuration ensues, with numerous fistulse, and constant pocketing 
 
 Fig. 757. — Extensive scars of both hyper- 
 chondriac regions from previous operations 
 for necrosis of ribs. Episcopal Hospital. 
 
732 SURGERY OF THE ANTERIOR MEDIASTINUM 
 
 of "hot" pus, which requires evacuation (Fig. 757). If seen before 
 rupture occurs, the abscess should receive tlie treatment advised for 
 cold abscess in general (p. 483). 
 
 Tuberculosis may also affect the joints of the sternum; at the 
 junction of the manubrium and gladiolus its development has been 
 mistaken for fracture (N. B. Carson). 
 
 Acute septic osteomyelitis of the ribs may occur, but is rare; also 
 rare is typhoid periosteitis of the ribs, which may not develop for 
 months or years after the attack of typhoid fever. Osteomyelitis 
 may result in necrosis of the ribs, and resection of the portions affected 
 may be required; in cases of typhoid origin, however, curettement 
 of the carious surfaces usuallv is sufficient. 
 
 SURGERY OF THE ANTERIOR MEDIASTINUM. 
 
 Affections of the anterior mediastinum offer up to the present a 
 very limited field for surgical care. 
 
 Acute Mediastinitis. — Acute mediastinitis is the term used for a 
 cellulitis of the mediastinum. It may follow a stab or gunshot wound, 
 or may result from extension downward of a cervical cellulitis. 
 There are pain, tenderness on pressure over the sternum, and con- 
 stitutional symptoms of sepsis. Signs of cardiac, pulmonary, or 
 tracheal compression may arise. Usually in the course of time pus is 
 formed, and this seeks an exit for itself through an intercostal space 
 close to the sternum, or possibly by rupture into a bronchial tube or 
 the pleura. Lymphadenitis of the mediastinum usually is tuberculous. 
 The onset of symptoms is less acute than in mediastinitis. 
 
 Treatment. — When medical measures, w'ith cold locally, fail to 
 relieve the symptoms, and especially when symptoms of respiratory 
 obstruction arise, surgical intervention is called for, even before 
 pointing of an abscess occurs. The operation consists in trephining 
 the sternum, enlarging the opening with rongeur forceps, and evacuat- 
 ing the pus by Hilton's method (p. 51). An abscess may be opened 
 where it points, but even then it is usually necessary to cut away 
 part of the sternum to secure free drainage. 
 
 Mediastinal Tumors. — These give evidence of their presence by 
 compression symptoms, and by an abnormal area of dulness on 
 percussion. Tuberculous lymphadenitis is the most frequent non- 
 neoplastic growth. The lymphadenoid enlargements of Hodgkin's 
 disease and sarcoma are not so frequent as secondary desposits of 
 carcinoma. Benign tumors, especially dermoids, also occur. As a 
 rule no surgical treatment offers any prospect of cure; but palliation 
 may be offered by splitting the sternum longitudinally to lessen the 
 symptoms of compression. Should a benign tumor be found, it might 
 be removed successfully. Friedrich recommends transverse section 
 of the sternum above the third rib. Enlargement of the thymus 
 gland is referred to at p. 693. 
 
PENETRATING WOUNDS OF THE THORAX 733 
 
 SURGERY OF THE LUNGS AND PLEURA. 
 
 Subcutaneous Injuries. Siilxutaiu'ous injuries of the thoracic 
 viscera usually arc accompanied by fractures of the ribs or sternum; 
 but sometimes tlie hm<f is ruptured without there being any coinci- 
 dent injury of the elastic thoracic cage. In most cases the lung is 
 directly crushed, but it is possible for it to be injured by wTenching 
 from its pedicle, or by being torn loose from pleural adhesions. The 
 extent of the lesion varies from mere bruising to extensive laceration, 
 and the resulting hemorrhage may be slight or very severe. In the 
 mildest cases the visceral pleura is not ruptured, and the symptoms 
 are those of a localized pneumonia, possibly with the development 
 of subcutaneous emphysema commencing at the root of the neck 
 (p. 728). When the visceral pleura is ruptured, hemorrhage occurs 
 into the pleural cavity, and the air also usually escapes from the 
 lung, forming a pneumo-hemothorax. 
 
 Diagnosis. — The diagnosis depends on ascertaining the history of an 
 injury; on the symptoms, which do not differ from those of pene- 
 trating wounds of the lung (see below); and on the physical signs 
 of pneumothorax and surgical emphysema. The diflferential diagnosis 
 from traumatic diaphragmatic hernia may be difficult; this is dis- 
 cussed at (p. 751). 
 
 Treatment. — The treatment consists primarily and chiefly in 
 rest, either in the recumbent or sitting posture, whichever is more 
 comfortable to the patient. I believe the administration of opium 
 in some form is decidedly beneficial, allaying the annoying cough, 
 slowing the respiration, and, therefore, diminishing the bleeding. In 
 many cases the bleeding stops of itself. The blood-pressure in the 
 pulmonary system is only one-third of that in the systemic. If 
 bleeding does not cease, as indicated by persistent symptoms of 
 internal hemorrhage, and by gradual increase in the amount of pleural 
 effusion, it must be checked by operative means, as described below 
 in connection with penetrating wounds of the lung. If the pneumo- 
 thorax persists and causes dyspnea, the air may be aspirated; for 
 this a very fine needle should be used, as less liable to cause sub- 
 cutaneous emphysema. The surgeon should not resort to this measure 
 unnecessarily, since relief of the pneumatic pressure on the lung may 
 cause recurrence of bleeding. 
 
 Prognosis. — The prognosis is grave except in the case of trivial 
 lesions. ]\Ioller, in 1910, reported 23 cases from Korte's clinique; 
 no operation was attempted in any case, and none would have been 
 of any avail in the 9 fatal cases. 
 
 Penetrating Wounds of the Thorax. — These are chiefly gunshot 
 or stab wounds. The former have been considered at (p. 189). In 
 most cases of stab wounds the lung is injured, but penetration of 
 the parietal pleura without visceral injury is possible. In the latter 
 case intrapleural hemorrhage (hemothorax) may occur from injury 
 of a vessel in the thoracic wall; and there usually is pneumothorax, 
 
734 SURGERY OF THE LUNGS AND PLEURA 
 
 air being sucked into the pleural cavity at each inspiration. Com- 
 plicating injuries of the diaphragm and abdominal viscera are fre- 
 quent. If the lung has been wounded there may be considerable 
 shock, Avith dyspnea, rough, and usually spitting of blood (hrinopfysis). 
 In many cases there are the symptoms of severe internal hemorrhage 
 (p. 227). The physical signs are those of pneumothorax, or hemo- 
 pneumothorax; sometimes there is hemorrhage from the wound. 
 Escape of air from the wounded lung through the external wound 
 occasionally occurs; it is known as tranniaiopnea, and should not 
 be confused with the mere aspiration of air into the pleural cavity 
 such as was described as occurring even when no pulmonary injury 
 is present. Prolapse of the lung through the wound is a rare occur- 
 rence; this should not be confused with subcutaneous hernia of the 
 lung, which is described at p. 73(5. 
 
 Diagnosis. — Usually this is not difficult. But it should be remem- 
 bered that alarming intrapleural hemorrhage may occur from injuries 
 of the internal mammary and intercostal arteries, without wound of 
 the lung; and the possibility and extreme seriousness of complicating 
 stab wounds of the diaphragm (p. 749) should be kept in mind. 
 
 Treatment. — The constitutional treatment is the same as for gun- 
 shot wounds or subcutaneous rupture of the lung. Under no cir- 
 cumstances should the wound be explored with finger or probe. 
 The surrounding skin should be painted with 3 per cent, alcoholic 
 solution of iodin, the wound should be covered immediately with 
 sterile gauze, and the side of the chest affected should be firmly 
 strapped as in the case of fractured ribs. This materially alleviates 
 the patient's pain, though probably it has little influence on the 
 progress of the wound in the lung. 
 
 The question of the propriety of early operative interference in thoracic 
 injuries has been the subject of much discussion during the last 
 few years; and some surgeons are very uncompromising in their 
 attitude for or against intervention. The debate is waged chiefly 
 over the subject of stab wounds, the propriety of non-interference 
 in the case of gunshot wounds, except for positive indications, being 
 very generally recognized. In the case of subcutaneous injuries, 
 also, a decision for or against operation is not very difficult, because 
 the symptoms either are so trivial as never to raise the question, or 
 the lesions are so manifestly lethal in extent as to render operation 
 useless. But in the case of stab wounds there are those who teach 
 that operation is never or hardly ever required; and there are others, 
 equal in experience and authority, who maintain that every patient 
 with a stab wound of the thorax, seen within the first twelve hours, 
 should be taken at once to the operating room, and that the question 
 of operative or non-operative treatment should be decided only 
 after an exploratory operation has been done to determine by 
 inspection the extent of the lesions. Zeidler, of St. Petersburg, 
 with an immense experience in this class of cases, takes the latter 
 ground; and his assistant Lawrow (1911) has exposed his views very 
 
PENErRATING WOUNDS OF THE THORAX 735 
 
 thoroughly. Other tilings hcinjj equal, tliis no doubt is the logieal 
 position to take; but tlie fact remains that if it is adhered to, a great 
 many unnecessary oj)erations will be done; and in many cases the 
 patients will be made worse or will be killed by the exploration. 
 
 Most surgeons recognize tiiat stab wounds which might involve 
 the diaphragm or abdominal viscera should be explored; and the 
 fact that oo out of 121 stab wounds of tiie thorax (Lawrow) came 
 within this category should be born(> in mind. It is recognized, 
 moreover, that wounds which probably injure the heart should be 
 explored (p. 286); according to Lawrow's figures only one out of 
 ten stab wounds of the thorax implicates the heart. But when these 
 two classes of stab wounds are excluded, there certainly remains a 
 large number of cases in which it is at least extremely proba})le that 
 only the lung has been injured, or that even though the pleura has 
 been penetrated there is no visceral injury whatever; and it is interest- 
 ing to compare the results secured in the case of uncomplicated 
 pulmonary wounds in Zeidler's service, where every patient who con- 
 sented was subjected to early operation, with those reported (1910) by 
 IMoller from Korte's clinique, where no operations were done in such 
 cases. According to Zeidler's immediate exploration plan the mor- 
 tality in 52 uncomplicated cases was 27 per cent.; whereas Korte 
 treated 19 such cases without one death. And the significance of 
 this comparison I believe is not altered by the fact that in 78 per 
 cent, of the cases explored by Zeidler and his assistants some visceral 
 injury or bleeding from an intercostal vessel was found. 
 
 From a consideration of these facts I think it is evident that no 
 hard and fast rules can be laid dow^n for treatment, but that each 
 individual case must be treated on its own merits. In fully equipped 
 hospitals, I believe exploratory operation for stab wounds of the 
 thorax will be indicated more often in the future than in the past; 
 certainly more often than in the case of gunshot wounds or crushes. 
 But I cannot believe that exploration in every case is necessary or 
 desirable. If there is a possibility of injury of the heart, or of 
 the diaphragm or abdominal viscera, exploration is imperative; but 
 if this possibility seems remote, it is better to treat the patient 
 expectantly. 
 
 As indications for operation, then, may be recognized the following 
 factors : 
 
 1 . Possibility of injury to the heart, to the diaphragm, or abdominal 
 viscera. 
 
 2. Active hemorrhage from the wound. 
 
 3. Signs of internal hemorrhage, recognized by constitutional 
 symptoms, and by steady increase in the amount of the hemothorax. 
 It makes no difference whether this comes from the wounded lung 
 or from a parietal vessel. The bleeding must be stopped. 
 
 4. Pneumothorax which develops suddenly some days after the 
 injury. As pointed out by Moller this indicates sloughing or reopening 
 of the wound in the lung; and immediate drainage of the pleura is 
 
736 SURGERY OF THE LUNGS AND PLEURA 
 
 required to prevent sepsis. Primary pneumothorax scarcely ever 
 will be so severe as to demand relief; but if necessary the air may 
 be aspirated through a fine needle. If this fails, the only relief lies 
 in thoracotomy, by which the pressure within the pleura may be 
 reduced to that of one atmosphere. 
 
 Operation. — Usually a general anesthetic is required. Ether is 
 the best, and if possible it should be administered by intratracheal 
 insufflation (p. 154). The wound is carefully explored, cutting down 
 layer by layer, until it is ascertained that the pleura has been entered. 
 Then the incision is extended to a length of sLx or eight inches in the 
 wounded interspace. By strong retraction of the ribs (for which the 
 rib-spreader of ^Mikulicz is convenient) it may be possible to complete 
 the operation without resecting any of the ribs. Resection of one 
 or both ribs bordering on the primary incision may be done later if 
 necessary. A bleeding intercostal vessel, which may be the only 
 source of hemorrhage, should be looked for and ligated. The pleura 
 having been widely opened, the thoracic cavity is tamponed (by 
 fine silk tampons or those of handkerchief gauze if these are available), 
 and the diaphragm is inspected, unless there is good reason to believe 
 that it has not been injured. If a wound is found, it should be treated 
 as described at p. 750. If bleeding continues, the lung is caught 
 in volsellum forceps, and is drawn into the thoracic incision. This 
 fixes the mediastinum, promotes cardiac action, and ventilates the 
 other lung. The lung is then searched for wounds, and these are 
 sutured with mattress sutures of fine chromic gut, introduced close 
 to the border of the wound, passed deeply, but not drawn very tight. 
 Round-pointed needles should be used. A wound of exit as well 
 as one of entrance should be looked for. If the wounds cannot be 
 sutured, they should be packed; or a very extensive wound may be 
 "exteriorized" by suturing its margins to the edges of the parietal 
 wound. After the pulmonary wound has been sutured the lung 
 will expand if intratracheal insufilation is being employed, and the 
 blood which has collected in the pleural cavity will be forced out of 
 the thoracic incision. If it is not, the pleura should be wiped dry. 
 No irrigation should be employed. The parietal wound is then closed 
 in layers (pleura, intercostal muscles, and skin), icithoid drainage. 
 If the anesthetic has been administered in the usual way it will be 
 safer to leave a drainage tube in the incision for a few days; this 
 should be just long enough to enter the pleura. In 22 cases where 
 the wound was closed without drainage, subsequent drainage for 
 empyema or abscess was required in only 13 (Stuckey); the other 
 9 patients recovered without any complication, and if all had been 
 drained, all would have had empyema. 
 
 Hernia of the Lung is rare. When congenital it may be due to 
 defect in the chest wall, or may develop at the root of the neck. 
 Acquired cases usually follow some months or years after injury of 
 the thorax, the lung bulging out beneath the cicatrix. The swelling 
 is sponge-like in consistency, crepitates on pressure, and is reducible; 
 
HEMOTHORAX 737 
 
 it increases in size (iuriiij^ forced expiration, may disappear spon- 
 taneously during inspiration, and gives an impulse on coughing. 
 
 Treatment.- Treatment seldom is required. If support by pads or 
 adlit'sixc plaster does not secure relief, an operation may he under- 
 taken, dissecting out the cicatrix, and repairing the wound hy over- 
 lapping its edges in several layers. The pleural cavity need not be 
 opened. 
 
 Pneumothorax. — The presence of air in the pleural cavity as a 
 complication of injuries of the thorax has been alluded to. Occa- 
 sionally the condition arises from disease of the lung, usually tul)er- 
 culous; but such cases have little surgical importance. The pneumo- 
 thorax may be open or closed: that is, there may or may not be a 
 wound of the thoracic parietes producing a communication between 
 the pleura and the outer atmosi)here. If there is no external wound 
 (when the pneumothorax is due to escape of air from the wounded 
 or diseased lung), or if the thoracic wound is small or valvular, the 
 pressure of the air in the pleura may be increased at each respiration, 
 and a "tension pneumothorax" is said to exist. 
 
 Symptoms. — The symptoms depend upon the rapidity with which 
 the pneumothorax develops, and on the air pressure. A very suddenly 
 produced pneumothorax may cause immediate death from distortion 
 of the mediastinum, and interference with the action of the heart or 
 the other lung. One of very slow onset may produce no appreciable 
 symptoms. When traumatic in origin, the symptoms often are 
 obscured by those of shock, internal hemorrhage, etc. Unless the 
 lung is bound down by adhesions, the air fills the entire pleural cavity, 
 and the entire side of the chest affected becomes tympanitic on 
 percussion. There is absence of respiratory movements, no breath 
 sounds are heard, and vocal fremitus is absent. If the air is under 
 extremely high pressure a dull note may be obtained on percussion; 
 this is rare. Almost always there is dyspnea; there may be cyanosis; 
 the cardiac action may be embarrassed, and the pulse usually is weak, 
 not very rapid, and may be irregular. 
 
 Treatment. — In most cases of closed imeumotJiorax the air will be 
 absorbed spontaneously within a few days, and no treatment is 
 required. If dyspnea is severe the air may be aspirated. For this 
 a very fine needle should be used, so as not to produce subcutaneous 
 emphysema. In cases of o])en pneumothorax relief of symptoms 
 usually follows closure of the external wound by suture or occlusive 
 dressing. This restores the piston action of the diaphragm, ventilates 
 the other lung, and facilitates heart action. If for any reason the 
 wound cannot be closed, and the symptoms of a tension pneumothorax 
 supervene, it is better to enlarge the parietal wound or to introduce 
 a drainage tube, thus reducing the intraplem-al pressure to that of 
 one atmosphere. 
 
 Hemothorax. — Blood in the pleural cavity almost invariably is 
 the result of injury to the thorax, either subcutaneous or penetrat- 
 ing. The hemorrhage may be derived from the lung or from the 
 47 
 
738 SURGERY OF THE LUNGS AND PLEURA 
 
 internal mammary or one of the intercostal vessels. Bleeding from 
 parietal vessels is not likely to stop of its own accord, owing to the 
 negati\'e pressure within the pleural ca^aty. If the bleeding comes 
 from the lung it will not cease until the intrapleural pressure equals 
 the blood-pressure within the lung; but as this is only one-third as 
 great as that in the systemic circulation, intrapleural hemorrhage 
 from a lung wound will stop of itself much sooner than will bleeding 
 from an intercostal artery. 
 
 The physical signs are those of pleural effusion. The symptoms of 
 internal hemorrhage iuflicate the nature of the effusion, and this 
 may be proved by as])iration. The blood does not clot very readily, 
 and forms an excellent cidture medium for bacteria. Hence there is 
 great danger of secondary empyema. If infection does not occur, 
 and the blood finally clots and becomes organized, extensive and 
 perhaps disabling pleural adhesions may develop. I have operated 
 on a patient with calcification of the entire pleura, the result of 
 injury many years previously. 
 
 Treatment. — This depends upon the rapidity of the hemorrhage as 
 well as upon its extent. Rapid bleeding (indicated by the symptoms 
 of internal hemorrhage and by rapid increase in the amoinit of fluid 
 in the pleura) usually indicates an extensive pulmonary lesion, and 
 demands operation, as described under stab wounds of the lung 
 (p. 736). If the bleeding is slower, it is better not to interfere unless 
 the upper level of the dulness (in the sitting posture) ascends as high 
 as the spine of the scapula, or unless the symptoms of hemorrhage 
 are very pronounced. 
 
 Pneumc-hemothorax. — Pneumo-hemothorax is more frequent than 
 either pneumothorax or hemothorax separately. The air rises to the 
 upper part of the pleural cavity, and the blood gradually accumulates 
 below. The physical signs are those of pyo-])neum()thorax, which 
 are described in every text-book of general medicine. The diagnosis 
 depends on a recognition of these, and on a history of recent injury 
 and on the symptoms of internal hemorrhage. Aspiration of the 
 fluid pro\'es its hemorrhagic nature. Differentiation from diaphrag- 
 matic hernia (p. 751) may be difficult. Treatment has been discussed 
 sufficiently under the separate headings pneumothorax and hemo- 
 thorax. 
 
 Chylothorax. — Chylothorax usually is due to rupture of the thoracic 
 duct, which may occur as a complication in some cases of fracture of 
 the spine. The effusion is left-sided, but owing to more serious injuries 
 often is overlooked. Rapid emaciation is characteristic, but the 
 diagnosis cannot be certain until some of the fluid has been withdrawn 
 by aspiration; and microscopical and perhaps chemical stiuiy may be 
 necessary then to determine its nature, as an effusion similar in 
 macroscopical appearances sometimes occurs in cases of malignant 
 disease of the pleura. Treatment is unsatisfactory. In some cases 
 repeated aspiration has been followed by recovery. 
 
I'YO'rilOh'AX, OU KMI'YKMA TIJOh'AClS ToO 
 
 Hydrothorax. llydiolliorax is tlio lonu used to »k'scril)(' a collec- 
 tion of noii-iiiHammatory fluid (transudate) in the pleural cavity. It 
 presents little suru'ical interest. 
 
 Pleurisy or Pleuritis is an inHunHiuition of the pleura, almost 
 iu\arial)ly of bacterial origin, and in the vast majority of cases due to 
 infection transmitted from the lung. It may result from hematogen- 
 ous infection, but this is rare. It is always present in some degree 
 in cases of ])enetrating wounds of the thorax. In the early .stages of 
 the inflanunation a plastic exudate is formed, and if the ])rocess stops 
 here, recovery with more or less extensive pleural adhesions may 
 occur. Such cases form about one-fifth of the total cases of pleurisy 
 (Fraley, 11)07) and seldom come under surgical care. In about three- 
 fifths of ( ases serous eft'usion occurs, and in about one-fifth more this 
 eti'usion finally becomes i)urulent (pyo-thorax). If adhesions have 
 formed early, or in a previous attack of pleurisy, the effusion may be 
 encapsulated; its site then may be between the lung and the parietal 
 pleura, between two lobes of the lung, or between the lung and dia- 
 ])hragm. In cases where there are no adhesions the fluid lies free in 
 the pleural cavity and forces the lung upward and backward into the 
 spinal gutter. The symptoms of pleurisy with effusion are detailed 
 in every text-book on general medicine, and need not be recounted 
 here. The diagnosis is confirmed by exploratory puncture with an 
 aspirating syringe. 
 
 Treatment. — If the eiTusion is large and if no tendency to reabsorp- 
 tion is manifested, and particularly if the constitutional .symptoms 
 indicate suppuration, the fluid should be aspirated, as described at 
 p. 147. The needle is passed close to the upper border of the rib, 
 in the sixth, seventh, or eighth interspace, usually in the posterior 
 axillary line or below the angle of the scapula. The site may be 
 anesthetized by a hypodermic injection of cocain or by ethyl chloride 
 spray. Seldom is it necessary to withdraw all the fluid, as the relief 
 of tension secured by aspiration of a portion may hasten absorption 
 of the remainder. 
 
 Pyothorax, or Empyema Thoracis, is a collection of pus within 
 the pleural cavity. It is the suppurative stage of pleurisy with 
 effusion; but in many cases suppuration occurs so rapidly that no 
 anterior stage of serous effusion can be recognized. In no case is 
 there any sharp line of distinction to be drawn between the two 
 conditions, as the serous exudate (when one exists) gradually becomes 
 sero-purulent, and this in turn assumes the usual character of pus. 
 The pus may sink to the bottom of the pleural cavity as a heavy 
 flocculent sediment, and the supernatant liquid may remain com- 
 paratively clear. 
 
 Pyothorax is most frequent in children, especially as a complication 
 or result of croupous pneumonia, the infecting organism being the 
 pneumococcus. Pneumonia if followed by empyema in from 5 to 10 
 per cent, of cases. In adults men are affected much oftener than 
 women, and the empyema results less often from a frank pneumonia; 
 
'40 
 
 SURGERY OF THE LUNGS AXD PLEURA 
 
 in many cases the staphylococcus or streptococcus is the infecting 
 organism, and these may appear as secondary infections in cases 
 originally caused by the pneumococcus, which is a short-lived organism. 
 Unless the pus is evacuated early, the parietal and visceral pleurae 
 become thickened, and a fixed cavity is produced, which will hinder 
 expansion of the lung even when the contained fluid has been removed. 
 Adhesions may also occur, within the pleura, and much oftener than 
 in cases of serous effusion the empyema is encapsulaied either on the 
 surface of the lung, between its lobes, or between the lung and dia- 
 phragm. In rare cases the pus may evacuate itself through one of 
 
 the bronchial tubes, or may per- 
 forate the diaphragm and form a 
 subphrenic abscess. In children it 
 is not unusual for a neglected 
 empyema to break through an in- 
 tercostal space and to point sub- 
 cutaneously. In adults this is 
 rare (Fig. 758). This condition is 
 described as an empyema neces- 
 sitatis. If the empyema ruptures 
 externally, which is very unusual, 
 a pleural fistula is left, and this 
 scarcely ever heals spontane- 
 ously. 
 
 Ssnnptoms and Diagnosis. — Usu- 
 ally the empyema is secondary to 
 some thoracic condition (pneu- 
 monia, bronchitis, injury) for which 
 the patient has been under treat- 
 ment. In children, in whom the 
 condition is most frequent, an 
 empyema very frequently is mis- 
 taken for an unresolved pneu- 
 monia; but this condition is rare 
 in children, and if an aspirating 
 s\Tinge is used, as it should be, 
 for exploration in such cases, the diagnosis will be quickly cleared up. 
 The physical signs in children may be very misleading, as the breath 
 sounds may be quite clearly heard; this, with the persisting dulness 
 on percussion, causes the resemblance to unresolved pneumonia. 
 There may be Skodaic resonance above the dull area. But tactile 
 fremitus is decreased, and the mere fact of a lingering pneumonia 
 in a child should make one suspect an empyema. Xor should failure 
 to draw pus at the first puncture make the physician conclude that 
 it is absent, if the constitutional signs of sepsis persist. The pus 
 may be too thick to run through the needle employed, or the collection 
 may be encapsulated, and may not have been reached by the needle. 
 In advanced cases, however, the diagnosis is easy; the temperature 
 
 Fig. 75&. — Empyema necessitatis, 
 pointing beneath left pectoral muscles. 
 Age thirtj--two years ; phthisis for two 
 j'ears: pneumonia seven months ago. 
 "Abscess in thorax" for five weeks. 
 (Dr. Harte's case.) Pennsylvania 
 Hospital. 
 
PYOTHORAX, OR EMPYEMA THORACIS 
 
 741 
 
 contimu's ok'Nutcd, and thoiifili remissions may occur daily or oftener, 
 the normal is not rtniclied. The apex beat of the heart may be dis- 
 placed l)y laro;e otVusions; the intorsi)aces of the affected side may 
 bnl^e; (Hlated veins may cover tliis side of the thorax; and it may 
 seem iarfjjer than the heahhy side, though its resj)irat()ry excursions 
 are less than normal or absent (Fig. 759). In adults the diagnosis of 
 pleural effusion does not present the same difficulties, but the presence 
 of pus rarely can be asserted positively unless j)aracentesis is done. 
 
 Treatment. — A child almost in articiilo moriis may be saved by 
 prompt evacuation of the pus, but the evacuation should not be 
 too rapid in any case where 
 there is marked dysjjnea, cya- 
 nosis, etc., as abrupt change 
 in the intrapleural pressure 
 may cause sudden death. In 
 any case of massive effusion 
 (one extending as high as the 
 spine of the scapula) it is 
 well to withdraw half or 
 three-fourths of the fluid by 
 aspiration before proceeding 
 to drain the chest. 
 
 Murphy's Method. — Mur- 
 phy aspirates the pus and at 
 once injects two or three 
 ounces of a 2 per cent, solu- 
 tion of Liquor Formaldehydi 
 (U. S. P.) in glycerin. This 
 solution should have been 
 made up at least twenty-four 
 hours previously, so as to 
 allow it to become thoroughly 
 mixed and sterile. A week 
 later the fluid is aspirated 
 again, and it is found less 
 purulent and more serous; 
 
 another injection of the formalin-glycerin solution is given, and at the 
 third or fourth aspiration the fluid is found to be pure serum. This 
 fluid is allowed to remain in the pleural cavity, and is very gradually 
 absorbed, as the lung expands and the chest wall sinks in. A year 
 or more may elapse before all the fluid is absorbed, but as it is sterile 
 the patient is in no way inconvenienced by its presence. 
 
 Few other surgeons have adopted Murphy's plan of treatment, 
 most preferring still to open the pleural cavity and drain the abscess. 
 Naturally the earlier Murphy's method is employed, the more success- 
 ful it will be; if employed as soon as the first evidences of suppuration 
 appear in a pleural effusion, one injection may suffice for a cure. 
 But in cases of long standing, where the pleura is much thickened 
 
 Fig. 759. — Pyothorax on the left, following 
 pneumonia. Age seven years; duration two 
 weeks. Note x on apex beat, displaced to 
 right; dyspneic expression; bulging of left 
 intercostal spaces, and well marked intercostal 
 depressions on right. Children's Hospital. 
 
742 SURGERY OF THE LUNGS AND PLEURA 
 
 and the limir is hound down by adhesions, I think tlioracotoniy, as 
 (U'scrihed below, is to be preferred. 
 
 Thoracotomy or Plevrotomy. — This is the oi)eration of opening the 
 thoracic cavity for the purpose of draining an enii)yeina; a ])()rti()n 
 of a rib is excised to ensure free drainage (Konig, 1878). The rib 
 selected depends on the location of the pus, if this is encapsulated ; 
 if the pus is free in the pleural cavity the surgeon chooses the sixth 
 rib in the anterior axillary line, the seventh in the mid-axillary line, 
 or the eighth rib in the posterior axillary line. It is said that if a 
 lower rib is chosen, the ascent of the diaphragm may interfere with 
 drainage; and if too high a rib is selected it may be above the level 
 of the pus, and the lung may be injured. T. T. Thomas (1913) 
 advocates resection of the eleventh rib close to the angle to secure 
 dependent drainage, and secure prompt closure of the sinus. In 
 children some surgeons prefer an intercostal incision, without resec- 
 tion of a rib, but I believe even in these cases convalescence is more 
 rapid if a larger opening is made. 
 
 The operation may be done under local anesthesia if necessary: 
 after anesthetizing the skin and subcutaneous tissues as usual, the 
 needle is inserted in the intercostal space at the dorsal extremity of 
 the proposed incision, and is pushed in until it strikes the rib, its 
 point is then manipulated until the lower border of the rib is found, 
 whereupon it passes through the elastic resistance offered by the 
 external intercostal muscle; it is then pushed still a little further in, 
 and about 2 c.c. of a 1 per cent, solution of cocain are injected around 
 the intercostal nerve. This procedure is repeated in the interspace 
 next below^; and after a few minutes the intervening rib may be 
 painlessh^ resected. In many cases, especially in children, a general 
 anesthetic (ether) is to be preferred. Dyspnea should be relieved 
 by aspirating most of the pus l)efore beginning the operation. The 
 patient is not to be turned o\'er on the healthy side, as this may cause 
 arrest of respiration or cardiac action. By bringing the body well 
 over the side of the table the operation may be done without much 
 difficulty, as the patient lies supine. Of late I have always followed 
 Elsberg's suggestion to have the patient lie prone; respiration is 
 perfectly easy in this position and the operative pneumothorax 
 causes less pulmonary collapse than in the usual position. 
 
 An incision of about tliree inches is made along the rib selected, 
 and the knife is carried directly down to the bone. Bleeding-points 
 are clamped. The periosteum is incised and is stripped from the 
 outer surface of the rib throughout the length of the incision, by means 
 of a periosteal elevator. On the upper surface of the rib strip the 
 periosteum from behind forward, and on the inferior surface strip 
 it from before backward. Then the periosteum is also stripped from 
 the deep (pleural) surface of the rib, keeping the instrument close 
 to the })one. By this means the intercostal ^'essels, which are separated 
 from the rib by its periosteum, are pushed aside with the soft parts. 
 When the rib has been thus denuded throughout its entire circumfer- 
 
I'YOTIIOUAX, Oh' EMPYEMA TIIOUACIS 
 
 'AW 
 
 Fig. 760. — Excision of a rib for empyema. 
 
 eiK-e for a distaiur of about two iiiclics, a boiu'-cuttiiiK forcrps or a 
 special costotoinc i.s used to divide the rib at one end of the incision. 
 The portion of rib to l)e excised is tlien <rrasi)ed in forceps, and the 
 rib is (li\i(icd at the other end of the incision (Fig. 7()()), and the 
 intervening portion is removed. Tliis siiould l)e at least an inch and 
 a half long. The parietal i)leura, still covered by the deep layer of 
 the ])eriosteuni, then presents in 
 the wound; these structures 
 shoukl be divided in the axis 
 of the rib for an inch or more. 
 In some cases of long standing 
 empy(Mna the i)arietal pleura 
 may be half an inch thick. 
 There is little danger of wound- 
 ing the lung, but it is well to 
 take the same ])recautions as in 
 opening the peritoneum (p. 821 ). 
 
 The intercostal vessels often are thrombosed, and may not bleed if 
 woimded ; if the periosteum has been stripped carefully from the rib 
 before this is excised, and if the deep incision is made nearer the 
 upper than the lower, border of the rib, these vessels will not })e 
 wounded. If they are wounded, bleeding from them is controlled 
 more easily by a mass suture than by a ligature. 
 
 As soon as the pleura is opened the anesthetic may be stopped. 
 Usually only a few minutes are required for the whole operation. 
 The pus should be allowed to escape slowly. Violent paroxysms of 
 coughing may occur. The surgeon should introduce his finger from 
 time to time, to assist the discharge of masses of lymph. If the 
 empyema is of long duration, it is well to break up adhesions between 
 the chest wall ancl lung, so as to facilitate its subsequent expansion. 
 In such old cases the infection is not very virulent, and septic absorp- 
 tion is not to be feared. In acute cases, where the infection is more 
 active, the lung is not firmly bound down, and its release, therefore, 
 is not necessary. 
 
 A large rubber tube (at least half an inch in diameter) is then 
 passed just within the parietal pleura, and is fixed by a stitch to the 
 margin of the skin wound. If not thus fixed it may fall into the 
 pleural cavity or be pulled out of the wound accidentally. An ex- 
 tremely abundant dressing of gauze and absorbent cotton is applied, 
 and the patient is returned to bed. 
 
 After-treatment. — The dressing may require changing several times 
 daily at first. INIasses of lymph blocking the tube should be removed 
 with forceps. No irrigation of the cavity should be employed. In 
 some instances this has caused death. As soon as agreeable the 
 patient should be propped up in bed, and measures must be adopted 
 to promote expansion of the lung. Every time the clock strikes 
 the hour the patient should be instructed to take a half dozen or more 
 deep respirations, and several times daily he should blow water from 
 
744 
 
 SURGERY OF THE LUNGS AND PLEURA 
 
 one Wolff's bottle to another (Fig. 701). Children may exercise their 
 lungs by blowing up toy balloons, sounding trumpets, etc. Patients 
 should be got out of bed as soon as possible. 
 
 Fig. 761. — Blowing through Wolff's bottles to expand lung after thoracotomy 
 for empyema. Episcopal Hosjjital. 
 
 Convalescence often is tedious, and may be interrupted by pneu- 
 monic or pleuritic attacks, with evidences of septic absorption. 
 This sometimes is due to interference with drainage of the wound. 
 In favorable cases the tube does not require to be replaced when 
 once removed at the expiration of ten days or two wrecks. As judged 
 by the results of operation, the mortality from empyema is about 
 20 to 25 per cent.; but as practically all patients die unless operated 
 on, and as the death rate from the primary pneumonia is very high, 
 the operation must be regarded as a distinct life-saving measure. 
 
 Bilateral Empyema. — Bilateral empyema is most frequent in 
 children. Fabrikant (1911) has collected 118 cases, with a mortality 
 of 37 per cent. The second side should be operated on a few days 
 after the first. 
 
 Pleural Fistula. — Pleural fistula may persist for years after the evac- 
 uation of an empyema, unless properly treated, and may lead to death 
 from exhaustion, amyloid degeneration of the viscera, secondary 
 tuberculosis, or some intercurrent disease. If the emp}'ema has been 
 recognized early, and has been evacuated promptly, the resulting 
 sinus closes in a few months or less. It is in cases of clironic empyema, 
 where the lung is bound down by dense adhesions, that a large thoracic 
 cavity remains. From this a pint or more of pus may be discharged 
 daily; and when saprophytic infection is added, the discharge is 
 exceedingly putrid, and the patient is loathsome to himself and to 
 all around him. The thorax becomes deformed, curvature of the 
 
PLEURAL FfSTCLA 
 
 745 
 
 spine develops (Fig. 7(>2). Ji'^d the i)iitient is ii Iieij)less cripple. ( lul)- 
 hing of the fingers is frequent (Fig. 494), and other joint changes 
 may add to his misery (pnhnonarN' osteoarthroi)athy (j). 47(5). 
 
 Treatment. Treatment depends npoii the extent and duration of 
 the sinus. A small and recent sinus, which does not discharge \-ery 
 much pus, often may he made to 
 heal hy hisnuith paste injections 
 (Ochsner, 11)09), as us(>d for tuber- 
 culous sinuses (j). 4S4). This 
 method, with skiagraphy, is valu- 
 able in determining the size of the 
 cavity within the thorax. 
 
 When there is much purulent 
 discharge it is desirable to check 
 this before instituting any formal 
 oj)cration; and this is best accom- 
 plished l)y irrigation which may 
 be employed wnth safety in these 
 chronic cases. Potassium perman- 
 ganate solution is very satisfactory. 
 The cavity should be cleansed at 
 least once daily in this manner. 
 
 Sometimes the sinus is kept 
 from healing by the presence of a 
 drainage tube which has been lost 
 inside the wound. This may be 
 detected by a skiagraph, and its 
 removal constitutes the first step 
 in treatment. 
 
 If drainage is not free, tlie sinus should be enlarged, under an 
 anesthetic, and the surgeon should break up with his finger the 
 adhesions between the lung and parietal pleura; and if the cavity 
 is large, he should resect another rib at its most dependent portion, 
 and drain from the lower opening. 
 
 Information derived from use of the a:-ray may be an aid in the 
 prognosis: if the collapsed lung is permeable to air the a:-ray will 
 show decreased density during forced expiration; and if the lung 
 shows a tendency to expand during coughing, it is probable no further 
 operation will be required (Destot and Violet, 1904). For cases 
 in which the lung is permeable, but where no tendency to expansion 
 is apparent, decortication or discission, as described below, should 
 be done. If the lung neither shows a tendency to expand nor is 
 permeable to air, the only way to efface the pleural cavity is to resect 
 the bony thoracic cage overlying it, and thus to allow the soft parts 
 to fall in against the lung (Estlander, Schede). 
 
 Decortication of the Lung (Fowder, Delorme, 1893). — This consists 
 in opening the old cavity of the empyema by an intercostal incision 
 or the resection of a rib, obtaining sufficient exposure to enable the 
 
 Fig. 762. — Scoliosis, nine months 
 after operation for empyema; fistula 
 still discharges eight ounces of pus 
 daily. Episcopal Hospital. 
 
74(i SURGERY OF THE LUNGS AXD PLEURA 
 
 surgeon to explore the entire interior of the empyema cavity. The 
 most important step is to free the lung thoroughly from its attach- 
 ments to the parietal pleura. This is best done by making an incision 
 through the latter close to the outer or posterior margin of the lung 
 along the spinal gutter. The fingers are then inserted between the 
 posterior thoracic wall and the lung, and the latter is gradually 
 freed. Its natural elasticity and tendency to expansion aid in this 
 manoeuvre. When the lung is thus freed posteriorly it may be possible 
 to peel the remains of the abscess wall off its surface. The thoracic 
 wound is then closed with drainage, and the case is treated as one 
 of recent empyema. The results are very satisfactory, the lung 
 expanding and the abscess cavity becoming obliterated. 
 
 Discission of the Pleura (Ransohoff, 1903) is adopted in cases where 
 decortication proves difficult or impossible. If the dense membrane 
 overlying and compressing the lung is scored by the knife, down to 
 the lung tissue proper, the incision will gape widely; and if a number 
 of such incisions are made in parallel and criss-cross lines, each inci- 
 sion will gape so widely that the lung will expand to a very surprising 
 degree. 
 
 Thoracoplasty, Estlander's Operation (1877). — This consists in the 
 resection of several ribs (three to five), for a considerable extent, 
 directly over the old empyema cavity, in order to allow the soft 
 parts of the thoracic wall to fall in against the collapsed and non- 
 expansile lung. The cavity is thus wholly or in part obliterated. In 
 very large cavities the operation may not effect a cm-e, but the result 
 is "the difference between having a large abscess discharging a great 
 quantity of pus, and a small sinus which weeps a little thin fluid." 
 (J. Ashhurst, Jr., 1894.) The operation may well be combined with 
 free separation of the lung from its parietal adhesions, especially 
 po.steriorly — a modified form of decortication. Schede's Operation 
 (1890) consists in resection of nearly the entire bony wall of the side 
 of the thorax affected. This is exposed by reflecting an immense flap 
 extending from the second costal cartilage anteriorly, to the costal 
 margin below, and to the spine of the scapula posteriorly. After 
 removal of the ribs, this flap is applied against the exposed lung. 
 This operation has a high mortality and is rarely done at the present 
 day, when earlier and more thorough treatment of the acute empyema 
 enables the patients to recover without such immense cavities. In 
 no cases should it be attempted until decortication and Estlander's 
 operation have failed. 
 
 Tuberculosis of the Pleura, usuaUy secondary to that of the lung 
 or bronchial lymph nodes, presents little surgical interest except 
 in cases with effusion. Most painless, slowly developed, and appar- 
 ently causeless cases of pleural effusion in adults are tuberculous. 
 The condition is recognized by the physical signs of pleural eftusion, 
 and the nature of the fluid may be suspected from the patient's 
 history. Diagnostic puncture reveals straw-colored or slightly 
 turbid fluid, rarely blood-tinged. Tubercle bacilli seldom can be 
 
rrnKHciLosis of Tiih: Lcxas 747 
 
 (liscovcrcd, l)Ut a liij^li lym|)li()c\t(.' coiiiit iniiy.siijj;jft'st the tuberculous 
 nature of the Huid. and inoculation experiments usually will confirm 
 the diagnosis. 'Die coiKJition is to he regarded as one of cold abscess. 
 Sect)ndary infection, from the ))erforation of a tuberculous cavity 
 in the lung into the pleura, is not very uncommon, forming a pyo- 
 pneumothorax. Secondary infection may also occur through the 
 blood or from the unruptured lung. 
 
 Treatment. Local treatment is entirely secondary in importance 
 to the general treatment of the tuberculous patient. Only if the 
 effusion is massive, and causes dyspnea, should any of the fluid be 
 withdrawn by aspiration. If much fluid is withdrawn (hufiage may 
 be done to the diseased lung, or a recently closed communication 
 with the lung may be reopened. After some of the fluid is withdrawn 
 the remainder may be gradually absorbed. If on aspiration the fluid 
 is found to be verging on suppuration (from secondary infection), 
 an ounce or two of formalin-glycerin solution (2 per cent.), should 
 be injected. Under no circumstances should the pleura be opened 
 by incision, or drainage be established: such a course surely invites 
 secondary infection, with an external pyo-pneumothorax, and death 
 usually occurs in a few weeks. Secundary tuberculosis in an open 
 emjtyciua ravifi/ may occur, but is not so quickly fatal as a primary 
 tuberculous pleurisy secondarily infected. It should be treated as 
 other cases of open pneumothorax following empyema, with special 
 attention to the patient's general health. 
 
 Tuberculosis of the Lungs. — Surgery of this condition may be said 
 to be still in an experimental stage, and has been applied mostly to 
 advanced stages of the disease otherwise incurable. 
 
 In 1898 ]\Iurphy introduced to surgical notice in this country, a 
 plan of treatment, previously advocated (1882) by Forlanini, con- 
 sisting in injections of nitrogen gas into the pleural cavity, to cause 
 collapse of the lung and thus to induce rest and promote healing of the 
 pulmonary lesions. Nitrogen is said to be more slowly absorbed 
 than any other gaseous substance. Pneumonotomy, to drain cavities 
 in the lung, has been done on numerous occasions; the first formal 
 operation is the historic one of Baglivi in 1643. It is conceivable 
 that with the present improvements in the technique of pulmonary 
 surgery such operation may find a legitimate field in the future for 
 the rare cases in which an apical cavity is not draining well, and in 
 which no other discoverable tuberculous lesions exist. Partial pneu- 
 monecloniy was done by Tuffier in 1891 ; he removed the apex of one 
 lung, containing an early focus of tuberculosis. The patient recovered 
 and was in good health four years later. ^Medical and hygienic treat- 
 ment will cure such patients, and no operation should be done. Est- 
 landers Operation was suggested in 1891 by O. H. Allis as a means 
 by which collapse of a pulmonary cavity might be secured, with 
 improved chance of its healing; and this operation has been employed 
 by Quincke and others. Friedrich (1909) has employed Schede's 
 method for the purpose of causing collapse of a tuberculous lung, 
 
748 SURGERY OF THE LUNGS AND PLEURA 
 
 the other hmg being lieahhy, or exhil)iting no evidence of active 
 disease. Freeman (1909) resected the upper ribs, and after the wound 
 had liealed adjusted a hernial truss over the apex of the lung to cause 
 obliteration of a tuberculous cavity. Freund's operation of chon- 
 drectomy, as in cases of pulmonary emphysema, has also been employed 
 in cases of pulmonary tuberculosis, to overcome the thoracic rigidity 
 which prevents aeration of the lung. Freund in 1910 referred to 8 
 such operations in patients with pulmonary tuberculosis. 
 
 Pulmonary Emphysema. — W. A. Freund, having recognized since 
 1858 that some of these cases are caused by fixation of the chest 
 wall due to ossification of the chondral cartilages, proposed in 1906, 
 the operation of chondreciomy for their treatment. The costal cartil- 
 ages of the second, third, and fourth ribs on both sides of the thorax 
 are excised with their perichondrium, so as to prevent their regenera- 
 tion. The operation appears to have been employed in nearly fifty 
 cases, with a fair measure of success. 
 
 Abscess and Gangrene of the Lung, which are not very frequent, 
 may be regarded as different stages of the same affection. Most 
 cases occur in adults, and follow pneumonia; some cases follow a 
 pulmonary infarct from a septic focus elsewhere in the body; and 
 some follow the lodgement of foreign bodies. The patients usually are 
 in a very poor physical condition, with degenerations of the viscera, 
 before the pulmonary condition develops. 
 
 Symptoms. — Usually these develop rather suddenly as a compli- 
 cation of the preexisting disease. There is profound sepsis. Physical 
 examination reveals a localized consolidation in the lung, which may 
 give the signs of cavity after expectoration of its contained sputum. 
 The sputum from an abscess is great in quantity, and consists of 
 thick yellow pus, not malodorous at first. The older the abscess 
 the more fetid does the pus become, owning to saprophytic infection. 
 In cases of gangrene, which usually is a sequel to abscess formation, 
 this fetid character of the pus is very pronounced. If there is elastic 
 tissue in the sputum it is not probable that gangrene is present, 
 since saprophytic bacteria soon destroy it. Pleurisy, with adhesions, 
 frequently occurs and may prevent perforation of the abscess into 
 the pleural cavity with development of a putrid empyema. The use 
 of the .T-ray is of much value in localizing the abscess. If exploratory 
 puncture is done, it should be followed at once by operation. 
 
 Treatment. — Operation should not be delayed if gangrene is pres- 
 ent. The patient gets no stronger by waiting even for one day. 
 Without operation 80 per cent, of cases of gangrene of the lung 
 die. In Korte's 28 operations for abscess or gangrene, the mor- 
 tality was 28.5 per cent. (1909). In Lenhartz's 111 operations 
 for gangrene the mortality varied from 27 to 38 per cent. (1908). 
 If the abscess drains well through a bronchus, operation may be post- 
 poned. Whenever possible the operation should be done under anes- 
 thesia by intratracheal insufflation, though Korte administered the 
 anesthetic in the usual wav. The ribs overh'ing the site of the abscess 
 
STAB WOUNDS OF THE DIAl'lUiAdM 749 
 
 (whifh should ho (IcttTinincd het'orchaiidj are resected suhperios- 
 teally, for a distance of three or four inclies. If the lung is not 
 adhcTont to tlie pleura it should he sutured to it hy interrupted 
 mattress sutures of chroniic catpiut, applied in a circle around the 
 supposed site t)f the abscess. Soiuetinies the site of the ahsccss can 
 be detected by palpation, being denser than the surrounding lung 
 tissue. If the patient is not in very serious condition the second 
 stage of the operation is postponed for a couple of days. If the lung is 
 already adherent to the i)arietal })lcura, or if the patient's condition 
 is precarious, the surgeon proceeds at once to open the lung. This 
 is done by Hilton's method, first thrusting a grooved director into 
 the lung, and when pus is found dilating the tract with dressing 
 forcei)s. Some surgeons use the actual cautery for opening the abscess. 
 Any loose necrotic masses of lung tissue should be removed, but if 
 even lightly adherent they should not be disturbed The abscess is 
 drained by a tube. 
 
 Bronchiectasis. — For this condition surgeons do an operation 
 similar to that for abscess of the lung; but though the condition is 
 not curable by medical means, the cure by surgery may be worse 
 than the disease. The persistence of the bronchiectatic cavity may 
 not materially shorten the patient's life, and the risk of operation 
 is very great. In Korte's 17 patients the mortality of the operation 
 was 73 per cent. 
 
 Tumors of the Pleura and Lung may be primary, or secondary 
 to growths elsewhere. Primary growths are rare and very difficult 
 to diagnose. ]Most of them are malignant in nature. Endothelioma 
 and sarcoma occur in both lung and pleura, carcinoma onlj' in the 
 lung. Tumors of the pleura invade the lung, and those of the lung 
 soon attack the pleura. Of the secondary growths carcinoma is more 
 frequent than sarcoma. 
 
 Symptoms. — The symptoms are not clearly defined. Some cases of 
 primary carcinoma of the lung are mistaken for tuberculosis. There 
 is dulness on percussion, and the breath sounds are absent or may be 
 heard distantly. Exploratory puncture may reveal a bloody pleural 
 effusion, or there may be a dry tap. Blood in a pleural effusion signi- 
 fies either tuberculosis or malignant disease. There is no fever and 
 no leukocytosis. The increase in the physical signs is rapid. Cachexia 
 appears early and is pronounced. 
 
 Treatment. — There is little to do. If the pleura fills with fluid, 
 and this causes dyspnea, thoracentesis may be done. A few cases 
 of excision of portions of the lung have been recorded, the patients 
 surviving the operation (Lenhartz). 
 
 SURGERY OF THE DIAPHRAGM. 
 
 Stab Wounds of the Diaphragm. — In the majority of cases the 
 stab wound is received in the thorax, by a downward thrust, and a 
 complicating wound of the pleura exists. This is almost always the 
 
750 SURGERY OF THE DIAPHRAGM 
 
 case in stal) wounds inflicted by Slavs, but Italians frequently stab 
 their antagonists by an upward thrust, the stiletto entering the 
 abdomen first. The left side is more often injured than the right. 
 There are no characteristic symptoms, and the diagnosis can be made 
 with certainty only by exploratory operation, except in the rather 
 unusual cases in which the omentum or one of the abdominal ^'isce^a 
 protrudes through the thoracic wound. It is the frequency of injury 
 to the abdominal contents which renders these wounds so serious. 
 In 55 out of 121 consecutive stab wounds of the thorax, recorded by 
 Lawrow (1911), the diaphragm and abdominal organs were in\'olved. 
 The wound usually is in one of the lower intercostal spaces, espe- 
 cially between the seventh and tenth; but stab wounds as high as the 
 second interspace have caused injury to the diaphragm. The liver 
 is the most frequently injured of the abdominal viscera, then the 
 stomach or spleen (Magula, 1910). 
 
 Treatment. — Treatment is by immediate exploratory operation in 
 every case in which a lesion of the diaphragm is suspected. The 
 mortality without operation is nearly 90 per cent., and those patients 
 who have survived the immediate injury have perished eventually 
 from strangulation of a diaphragmatic hernia or other lesion which 
 a prompt operation could have prevented. Thoracotomy is the oper- 
 ation of choice, because by laparotomy it is \'ery difficult if not impos- 
 sible (1) to reduce the herniated organs, owing to the negative pressure 
 within the thorax, (2) to repair the wound of the diaphragm, (.3) to 
 suture wounds of the cardia or fundus of the stomach, or (4) to repair 
 damage to the lung. The technique of the operation is much the same 
 as that for diaphragmatic hernia (p. 752). If the stab wound is 
 abdominal, and laparotomy is employed as the primary operation, 
 secondary thoracotomy may be necessary before the herniated organs 
 can be replaced or the diapliragm sutured; such an operation is 
 described as thoraco-Japarotomy. By the term combined operation 
 is understood one in which the thoracic and abdominal cavities are 
 opened by the same incision: this is best made in the eighth inter- 
 space, dividing the ninth costal cartilage and the diaphragm as far as 
 necessary to secure free exposure. 
 
 If the case is not complicated by injury to the viscera, the mortality 
 with prompt operation is less than 20 per cent.; in complicated cases 
 it is about 05 per cent. (Magula). 
 
 Gunshot Wounds of the Diaphragm, except when complicated by 
 injury to the viscera, are so rare as to have little surgical interest, 
 unless strangulation of a hernia occurs subsequently through the 
 opening in the diapliragm. In most cases injuries of the thoracic 
 and abdominal organs exist, and the surgeon has to employ either 
 thoraco-laparotomy or the combined operation. 
 
 Rupture. — Rupture of the diaphragm, a subcutaneous injury, is 
 very rare. As extensive lesions of the abdominal organs are frequent, 
 Deaver and Ashhurst advise laparotomy as the primary operation, 
 so that hemorrhage and intestinal leakage may be controlled. If 
 
DIAPHRAGMATIC HERNIA 751 
 
 it is (lilliciilt to reduce tlie organs wliieii lia\'e l)eeii iierniated into tlie 
 thorax, tiioracotomy should be done also; this usually is required to 
 t'aeilitat(> repair of the diaphragm. 
 
 Diaphragmatic Hernia may be due either to congenital or to trau- 
 matic defect in the diaphragm. Owing to the negative pressure 
 within the thorax, it is always the abdominal organs whieh prolapse 
 through the opening. The most frequently herniated viseera are 
 the stomach, eolon, omentum, small intestine, liver, duodemnn. 
 and kidney — in the order named. Though a congenital defect may 
 be present at birth, the hernia may not appear until adult Mfe. and 
 may ])roduee no noteworthy symptoms until strangulation oecurs. 
 In owT 90 i)er cent, of cases the hernia is on the left side, because the 
 liver acts as a protection on the right. ^Nlo.st of the cases occur in 
 the fetus, or in infants stillborn or dying soon after birth. In adult 
 life sudden death from carrliac failure is a frequent termination, 
 and the possibility of a diapliragmatic hernia always should be re- 
 membered in considering the causes of sudden death. 
 
 Symptoms. — Subjecti^•e symptoms often are lacking, the malfor- 
 mation being found unexpectedly at autopsy. In the newborn, 
 cyanosis and dyspnea are prominent, the left thorax does not expand 
 properly, there is dextrocardia, and death usually results in a few 
 hours. The adult patient may have suffered from mild indigestion, 
 with distress after meals; but no alarming symptoms may arise until 
 sudden cardiac failure or perhaps death occurs from acute over- 
 distention of the herniated stomach. Strangulation is a frequent 
 termination, being due to any sudden strain which forces a larger 
 portion of the abdominal contents through the diaphragmatic opening. 
 
 The physical signs of diaphragmatic hernia are much more precise 
 in theory than in practice. Diagnosis of the condition in life, except 
 by the aid of the a;-ray, is exceptional. The lower chest on the 
 affected side is tympanitic, the breath soimds are very feeble and 
 distant, vocal fremitus is lost, expansion is decreased, and the heart 
 is dislocated away from the affected side. The same signs exist in 
 pneumothorax; but in diaphragmatic hernia the diaphragm does 
 not descend on deep inspiration, and causes which may produce 
 pneumothorax nearly always may be absolutely excluded. ^Moreover, 
 distention of the stomach with liquid will change the physical signs 
 in a case of diapliragmatic hernia; but in pneumothorax the thoracic 
 tympany and other signs will not be affected. Aspiration is to be 
 condemned as a method of diagnosis, owing to the great danger of 
 septic pleuritis or peritonitis. A history of sudden onset following 
 severe strain (sometimes childbirth) or crushing injury, or occurring 
 some years after a stab or gunshot wound of the thorax, is higlily 
 characteristic of diapliragmatic hernia. Finally the relation of the 
 stomach to the diaphragm may be determined by the use of skiagraphy 
 after filling the stomach with bismuth emulsion or introducing a 
 stomach tube filled with mercury. From the rare or congenital con- 
 dition known as eventration of the diaphragm, which is associated with 
 
752 SURGERY OF THE DIAPHRAGM 
 
 hyperplasia of the left lung, diapliragmatic hernia sometimes may be 
 distinguished by the history of the case, and by recognizing through 
 skiagraphy that the diaphargm in the former condition remains 
 still above the abdominal organs no matter how far upward into the 
 thoracic cavity these may protrude. 
 
 Treatment. — Immediate operation is required for recent diaphrag- 
 matic hernia of sudden development, because the danger of strangu- 
 lation is very great. Unfortunately most such cases are first seen by 
 the surgeon after strangulation has developed, and the patient is too 
 ill to justify the prolonged examination and numerous tests recom- 
 mended in seeking to reach a correct diagnosis. But if the surgeon 
 can ascertain that the patient has had a severe injury (crush, or pene- 
 trating wound of the lower thorax or upper abdomen) even many 
 years previously, the diagnosis and indications for treatment may 
 become very apparent. If the true condition is recognized thoracotomy 
 (Permann and Postempski, lSS9j should be done. In many cases inci- 
 sion in the eighth intercostal space, without resection of ribs, has given 
 adequate exposure. After packing off the lung with fine silk or hand- 
 kerchief gauze tampons, any rupture or perforation of the abdominal 
 viscera should be repaired, and they should be replaced within the 
 abdominal cavity. Then the opening in the diapliragm should be 
 sutured; when this is not possible the omentum may be stitched to 
 its margins, or as a last resort the opening may be tamponed. If 
 the operation has been done under difTerential pressure or with 
 intratracheal insufflation anesthesia, the pleura may be closed without 
 drainage. In other cases a tube should be left in for a few daj's. 
 
 If no diagnosis other than intestinal obstruction has been made, 
 laparotomy will be the operation employed; but if reduction of the 
 hernia from below proves impossible, no hesitation should be fe't 
 in proceeding to thoracotomy. 
 
CHAl'TKJi XXI. 
 IIKKXIA. 
 
 A hernia is a protrusion of a viscus through an abnormal opening 
 in the walls of the cavity within which it is naturally contained. This 
 is a general definition, and may he ai)plied to a hernia of a muscle 
 through a rupture in its sheath, to a hernia of the brain through an 
 artificial opening in the skull, or to a hernia of an abdominal viscus 
 through an abnormal opening in the abdominal \valls. By long 
 usage, however, the term hernia, when standing by itself, is applied 
 only to protrusions of the abdominal viscera. This protrusion usually 
 occurs through an aperture of the abdominal wall which transmits 
 bloodvessels or nerves, through a congenital defect, or through one 
 acquired as the result of operation or disease. If this protrusion occurs 
 through a normal opening it is not called a hernia, but a prolapse; 
 as a prolapse of the rectum through the anus, or of the uterus through 
 the vagina. The term hernia also implies that the protruding struc- 
 tures are still Covered by skin: thus when omentum or other structure 
 protrudes through an incised wound of the abdomen, it is not called 
 a hernia but a prolapse. 
 
 In the great majority of cases of abdominal hernia, the viscus which 
 protrudes carries before it a pouch of the parietal peritoneum, which 
 is called the sac of the hernia-; and since this sac may remain as a pro- 
 trusion even when it contains none of the abdominal viscera, a hernia 
 has been defined as "a protrusion of peritoneum liable to contain, 
 containing at times, or permanently containing any viscus or part of 
 a viscus from the abdominal cavity." (Da Costa.) But as the abdomi- 
 nal organs sometimes protrude through a part of the abdominal wall 
 which has no parietal peritoneum (e. g., a hernia of the bladder), or 
 slide down behind the parietal peritoneum, instead of carrying it before 
 them as a protrusion (e. g., sliding hernia of the colon), I think it is 
 better to cling to the old definition. If the sac protrudes and is 
 empty that patient has either a reduced or a potential hernia, accord- 
 ing to whether or not the sac has before been the seat of a hernia. 
 A sac may exist for many vears without a hernia developing in it 
 (p. 754). 
 
 Nomenclature. — A hernia receives its name (1) from the region 
 in tvhich it appears, as epigastric, lumbar, umbilical, inguinal, etc.; 
 (2) from its contents, as a hernia of intestine (enterocele), of omentum 
 (epiplocele), of bladder (cystocele), of rectum (rectocele), etc.; (3) 
 from its condition, as reducible, irreducible, inflamed, strangulated, 
 etc.; and (4) from its mode of development, whether of sudden develop- 
 48 
 
754 HERNIA 
 
 ment or slowly acquired. Various other terms, used in describing 
 hernia, will be explained as they are encountered. 
 
 Causes. — The predisposing causes of a hernia ma\' be either general 
 or local. 
 
 General Predisposing Causes. — (1) Age. Most hernise appear in infan- 
 tile or early adult life; the longer one lives the less apt he is to have a 
 hernia. But the number of old people alive is so much less than that 
 of young adults and children, that among the aged hernia is relatively 
 more common. (2) Sex. ]\Ien and boys are much oftener afflicted 
 with hernia than women. There are two main reasons for this: first 
 because of the weakness of the inguinal region in the male sex from 
 the descent through it of the testicle; and, second, from the more active 
 life men lead, and the greater frequency with which they are sub- 
 jected to great abdominal strains. (3) A distinct hereditary tendency 
 toward hernia is recognized, probably from the persistence of anatomi- 
 cal defects at points of greatest strain. 
 
 Local Predisposing Causes. — (1) Weakness of the abdominal wall. 
 After an abdominal operation, a hernia may develop in the scar 
 (incisional hernia, p. 772) : or as a consequence of injury to the motor 
 nerves of the inguinal region from an operation elsewhere, an inguinal 
 hernia subsequently may develop (Figs. 774, 788, and 792). Some- 
 times a hernia appears first after a debilitating illness or pregnancy. 
 (2) Increased strain upon the yarietes by the abdominal contents. The 
 gradual deposition of fat in the omentum and mesentery increases the 
 intra-abdominal tension, causes stretching of the parietal peritoneum, 
 opens up the hernial orifices, and thus predisposes to the development 
 of a hernia. The same train of events may occur in cases of ascites, 
 of intra-abdominal tumors, of pregnancy, etc. (8) A hernia may be 
 the effect of repeated efforts, in coughing, in straining at stool, in urinat- 
 ing (when there is some urinary obstruction) (Fig. 798). (4) The 
 existence of a congenital sac predisposes the patient to the develop- 
 ment of a hernia, though observations in the dissecting room show 
 that many patients with preformed sacs pass through life without 
 any evidence of a hernia. 
 
 Structures Composing a Hernia. — In a typical case a hernia is 
 composed of a pouch of parietal peritoneum, called the sac; of the 
 contents of the sac; and of its coverings, which are the structures of 
 the abdominal wall, muscles, fascia, and skin (Fig. 763). 
 
 Sac. — The sac, as noted already, sometimes is wholly or in part 
 deficient. Typically it is composed of a neck (that part which com- 
 municates with the peritoneal cavity), and a body (that part which 
 surrounds the protruding viscera). The apex of the sac is ']t<. fundus. 
 The sac may })e congenital or acquired. I believe, with Russell and 
 Murray, that the sac is congenital in a far larger proportion of cases 
 than is commonly thought. This preformed sac renders the patient 
 the potential possessor of a hernia; but until the hernia develops 
 ("comes down" is the colloquial expression), the i)resence of the sac 
 in most cases cannot be determined (p. 1058, congenital hydrocele). 
 
STRUCTURES COMl'OSISC A IIKRMA 
 
 755 
 
 Perito/ifum 
 
 .Transversalts /irsaa 
 Muscle 
 
 . . . Skin i Sup. fascur. 
 
 Fig. 763. — Diagram to show a hernial 
 sac, its contents and coverings. 
 
 The c()H(/rnilal .vac is fouud oftciu'st in inj^uinal liiTuia, Ijut occur.s 
 
 frequently also in the femoral form, and sometimes in umbilical 
 
 hernia. It nia\' he \ery lar<;e, hut usually is (juite small until distended 
 
 hy the protrudinji,' ahdoniinal contents. The arqnirrd .sac usually is 
 
 slowly developed from gradual stretching of the parietal peritoneum: 
 
 at first the neck of the acquired .sac is its widest part, hut as the sac 
 
 increases in size it becomes more 
 
 or less pear-shajjcd, the neck 
 
 being relatively narrow; then the 
 
 sac continues to increase in size 
 
 by the pressure of the contained 
 
 .structures, but, as a rule, the neck 
 
 does not enlarge at the same rate 
 
 but remains relatively small. The 
 
 wall of the sac, at first like the 
 
 neighboring ])arietal peritoneum 
 
 may become much thickened from 
 
 inflammation, and its neck may 
 
 undergo cicatricial contraction. 
 
 The sac usually becomes densely 
 
 adherent to the surrounding parts, 
 
 especially at its fundus; and 
 
 though the contents of the sac may be returned to the abdomen, 
 
 as long as the empty sac remains recurrence of the hernia is to be 
 
 expected. In hernia of long duration the neck of the sac may be 
 
 shifterl, by the pull of its contents, downward and toward the median 
 
 line of the body. 
 
 The Contents of the Sac may be almost any of the abdominal 
 viscera, but the most frequently herniated structures are the intes- 
 tine fenterocele), and the omentum (epiplocele). In infancy and 
 young childhood the omentum seldom is found in a hernia, owing 
 to its undeveloped state; but in adults, particularly those who 
 are obese, it is the most frequently found of all structures. The 
 lower ileum is the portion of the bowel most often found in a 
 hernia, because it has the longest mesentery and lies nearest the 
 inguinal and femoral openings. Hernia of the large bowel is infre- 
 quent, owing to its relatively short mesenteric attachments. The 
 cecum may be drawn into a hernia by a coil of ileum already there; 
 but the sigmoid is sufficiently mobile to find its own way into a hernia. 
 A single coil or several coils of intestine may be found in the sac, 
 or the hernia may be formed only by a portion of the wall of the intes- 
 tine; this latter condition (Fig. 764) is described as Richters hernia 
 (1778). A hernia of ^Meckel's diverticulum (Fig. 7()5) is known as 
 Littres hernia (1700). When the herniai contents remain long in the 
 sac, they usually become adherent to its walls and often are matted 
 together. In this way a hernia may become irreducible. When both 
 omentum and intestine are in the sac (entero-epiplocele), it usually is 
 the omentum which enters it first. The omentum generally lies in 
 
756 
 
 HERNIA 
 
 front of, or even completely surrounds the bowel, and the bowel may 
 be caught in apertures or depressions in the mass of omentum and 
 thus may become strangulated. Unless the hernia is inflamed or 
 strangulated there is little or no serum within the sac. 
 
 Fig. 764. — Partial enterocele, or Richter's hernia. Drawing made from a caee 
 of strangulated hernia in the Episcopal Hospital. 
 
 The Coverings of the sac \\ ill be described in connection with each 
 particular form of hernia. 
 
 «|]»i 
 
 Fig. 765. 
 
 -Littre's hernia — a hernia of one of the intestinal diverticula 
 (Meckel's diverticulum). 
 
 Reducible Hernia. — This is one in which the contents can })e replaced 
 within the abdominal cavity. It is the most frequent variety, since 
 almost every hernia is reducible when it first appears, and becomes 
 irreducible only after the lapse of years. For months or years before 
 the hernia appears the patient may have felt a weakness in the region 
 where the protrusion afterward develops. If the hernia develops 
 gradually, there may be at first the merest bulging of the parts during 
 straining efforts; later a small rounded tumor may be seen. This can 
 be reduced easily by the pressure of a finger, and usually disappears 
 spontaneously when the patient lies down. In cases of hernia prescjit 
 at birth, or of sudden though later development, or of long duratit)n 
 before seen by the surgeon, the protrusion often is of considerable 
 
REDUCUiLE IIF.RMA ITu 
 
 size. In time tiie greater part ol" the alxloiiiiiial contents may descend 
 into the sac. 
 
 Tlie ontline of a liernia is more or less ronnded or oval, usually 
 being less broad at the neck of the sac than elsewhere. The hernia 
 increases in size when the patient stands up, coughs, or strains; it 
 disap})ears either spontaneously or by gentle pressure when he lies 
 down; and in most cases it reappears again if he once more stands 
 up and coughs. When he coughs there usually is a distinct impulse 
 transmitted to the hernia, and this often can be seen and almost 
 always can be felt. 
 
 Enterocele. — If the sac contains intestine only, the hernia is smooth, 
 feels elastic, often gurgles on palpation, and usually is resonant on 
 percussion. The impulse is well marked. Reduction usually is 
 accompanied by a distinct gurgle and by a characteristic sensation 
 well described as a "flop." 
 
 Epiplocele. — An omental hernia feels denser, more fibrous or doughy 
 to the touch than an intestinal hernia; it is irregular in outline; gives 
 little or no impulse on coughing; and is dull on percussion. Reduction 
 is not accompanied by any gurgle, nor by the "flop" so characteristic 
 of bowel slipping back into the abdomen. 
 
 In the enter o-epiplocele the symptoms of the two separate forms are 
 combined. 
 
 It seldom is possible to ascertain what portion of the gut forms the 
 hernia. In umbilical hernia the transverse colon is most often found; 
 and in inguinal and femoral hernia, the ileum. The cecum is much 
 more frequent in right-sided inguinal hernia than elsewhere, but is 
 not very unusual in a left inguinal hernia. In femoral hernia the 
 omentum and small bowel are most often found. 
 
 Treatment. — It is necessary for a hernia to be cured, whenever 
 possible, because of the grave danger which may accrue to the patient 
 from the occurrence of strangulation. A cure can be obtained only 
 by an operation, by which the sac of the hernia is removed, its neck 
 closed, and the structures of the abdominal wall repaired in such a 
 manner as to prevent recurrence of a hernia. This is the best treat- 
 ment in every case in which an operation is not contraindicated ; 
 but the operation requires skill for its performance, and sometimes 
 is very difficult. It should not be attempted by the occasional operator. 
 Even if the best treatment (that which results in cure) is contra- 
 indicated or is refused, it is still necessary that the hernia be treated. 
 An untreated hernia tends constantly to grow larger and to become 
 irreducible. It is possible to keep a hernia reduced by the use of 
 apparatus (known as a truss) which exerts pressure over the neck of 
 the empty sac, and prevents descent of the hernial contents.^ It used 
 to be taught that in some cases the prolonged use of a truss might 
 cause obliteration of the hernial orifice by exciting adhesions of the 
 
 1 I mention only to condemn the attempts of some charlatans to cause closure 
 of the neck of the hernial sac by injecting paraffin in the surrounding tissues 
 (Fig. 766). 
 
75S 
 
 HERNIA 
 
 ( )]>!)( )si 11 (if layers of peritoneum. This oceasioiuilly occurs in infants, 
 hut in the vast majority of cases, though a truss may keep the hernia 
 reduced so long as the truss is in place, no obliteration in the neck of 
 the sac is caused, and its contents tend to return at once when the 
 truss is removed. If the neck of the sac becomes constricted from 
 prolonged use of a truss (and this is not unusual), the hernia will be 
 more apt to become strangulated, if it comes down, than if no truss 
 
 had been worn. If no treat- 
 ment at all is undertaken, the 
 hernia constantly increases in 
 size, is very apt to become 
 irreducible, and the patient 
 must endure the discomforts 
 of this condition as well as 
 run the added risk of stran- 
 gulation w^hich an irreducible 
 hernia entails. 
 
 The contraindications to 
 operation in the case of a 
 reducible hernia are only those 
 which contraindicate any 
 operation, however trivial (p. 
 760). There are no local con- 
 ditions which contraindicate 
 operation in cases of reduci- 
 ble hernia. Even immense 
 size of the hernial orifice, 
 with excessively weak ab- 
 dominal walls, is a condition 
 that may be overcome by 
 proper methods (p. 774). 
 K truss is an apparatus designed to support a hernia. It should keep 
 a reducible hernia reduced. It is applied around the body, and has a 
 pad which makes pressure over the hernial orifice. Most trusses are 
 for inguinal or femoral hernia, and are applied around the pelvis 
 between the iliac crests and the trochanters of the femora (Fig. 792). 
 A truss may be made of steel covered with leather or hard rubber, 
 causing elastic pressure over the hernial orifice; or it may be made 
 entirely of leather, and depend on the tension with which it is buckled 
 in place to retain the hernia. Trusses are also used for umbilical 
 hernise; and the abdominal belts, used to support ventral and inci- 
 sional hernia may be considered a form of truss. 
 
 There are certain featu res which ever}- truss should possess: it 
 should retain its position without extraneous aid; it should keep the 
 hernia reduced in all positions of the body, and during coughing, 
 sneezing, defecation, etc.; it should not cause irritation of the skin 
 overlying the hernia or elsewhere; and it should be easily kept clean. 
 The patient must have at least two trusses, in case one of them is 
 
 Fi( 
 
 AIa^~< 
 
 )f piirafiin in inguinal 
 
 canal and scrotum, injected on two occasions, 
 several months ago, in effort to cure a hernia 
 of twelve years' duration. Patient aged thirtj'- 
 eight years. Hernia now in scrotum. Epis- 
 copal Hospital. 
 
lliRKDVCllilJ': IIKUMA 7.V.) 
 
 hrokoii. I'lic trusses suital)lt' tor the (liU'crciit tonus of licniia will 
 he described under special licniia' (p, 7.SG). 
 
 Do (larnio says a jiatient wlio wears a truss is a eiirouic invalid, 
 and tlioufj;li this statement is somewhat of an exaggeration, it is 
 al)solutely true tluit such a i)Htient nuist ()l)serve certain rules of con- 
 duct if he wishes to continue in j^ood healtli. lie sliould he kept under 
 his pliysician's ohserx ation. A truss requires as strict oversight as 
 any other orthojjethc ai)i)liance (p. 517). The truss must always he 
 applied while the i)atient is recumhent, after reduction of the hernia; 
 it need not he worn at night, hut it should he reapplied every morning 
 het'ore the patient gets out of hed. It must never he taken off except 
 w'hen he is lying down. When he takes a hath he must wear the truss 
 in the tuh. lie must not make any sudden exertion or strain at any 
 time. He must lift no heavy weights. He must not go swimming. 
 He should he debarred from all athletics except the lightest exercises. 
 If he wants to be cured of his hernia, let him he operated on. Other- 
 wise he must endure the limitations which truss-wearing requires. 
 The possibility of strangulation of his hernia should he ever present 
 in his mind. Should it occur it will force him almost always to an 
 immediate operation to escape death; and he will be unable to 
 choose either the time, or the place, or the surgeon for such an 
 operation. 
 
 Irreducible Hernia. — The commonest causes for irreducibility of a 
 hernia are inflammatory adhesions affecting its contents. These may 
 he between the sac and its contents, or adhesions of the coils of bowel 
 to each other, to the omentum, etc. The most frequent cause is 
 adhesion of the omentum to the sac. The bowel rarely becomes 
 adherent to the sac. 
 
 Intravisceral adhesions often prevent reduction even when no 
 adhesions to the sac wall exist, because the contents are amal- 
 gamated into a mass too large to pass through the neck of the 
 sac. A hernia may be apparently irreducible, because manipulation 
 cannot force hack in a short time, through a small orifice, a large 
 mass of intestines or omentum which have taken years to descend. 
 There is no strangulation present in an irreducible hernia, though a 
 strangulated hernia may be irreducible. The diagnosis of an irre- 
 ducible hernia depends upon recognizing that the protrusion is at one 
 of the usual hernial orifices, on ascertaining tlie history of its develop- 
 ment, and on the physical signs, which are the same as in a reducible 
 hernia, with a few^ self evident exceptions. An irreducible hernia 
 presents an impulse on coughing; it constantly tends to become larger, 
 and the patient suffers from a sense of dragging, from digestive dis- 
 turbances, and often from intermittent attacks of constipation and 
 diarrhea. Though a patient may live for many years with an irre- 
 ducible hernia, he is in constant peril because the prolapsed viscera 
 are exposed to trauma, and are liable to repeated attacks of inflam- 
 mation or obstruction; and strangulation is much more apt to occur 
 than in the case of a hernia which is retained b^■ a truss. 
 
7G0 HERNIA 
 
 Treatment. — The cure of an irreducible hernia is more difficult and 
 dangerous than that of a simple hernia, and can he secured only by 
 operation. Except in the very old, or those with severe constitutional 
 or organic disease, or those with most enormous herniie, operation 
 always should be urged upon the patient. It is extremel}" desirable 
 to reduce the size of these large hernia^ before any operation is under- 
 taken, and even if no operation is done the patient may secure much 
 relief from the preliminary treatment. This plan is to keep the patient 
 in bed, on spare diet, with a course of mild purging, and frequent 
 enemas, so as to secure complete evacuation of the })owels. Absti- 
 nence and rest will reduce the amount of fat in the omentum and 
 mesentery; and recumbency, combined with elevation of the foot 
 of the bed, will bring the force of gravity to aid in securing reduction 
 in the size of the hernia. This method appears first to have been 
 advocated by Sir Astley Cooper in 1828. In most cases a partial reduc- 
 tion at least can be secured by resort to taxis (p. 766) after a couple of 
 weeks of this preparatory treatment, and sometimes the entire hernia 
 can be reduced. In these cases of immense hernia, if the surgeon 
 thoughtlessly undertakes an operation without such preparatory 
 treatment, he may find it impossible to make the viscera enter the 
 abdomen even after this has been opened. If the hernia can be 
 reduced to ordinary size before operation is attempted, this should 
 be as successful in obtaining a cure as in cases of reducible hernia. 
 
 If the patient refuses operative treatment, the application of some 
 form of support, in the nature of a "bag-truss" or suspensory may 
 somewhat alleviate the symptoms. 
 
 Inflamed and Obstructed Hernia. — These conditions are met with 
 almost solely in cases of irreducible hernia. Inflammation may occur 
 from accidental trauma, from unskilled or violent attempts at reduc- 
 tion, from the pressure of an ill-fitting truss, or from changes in the 
 contents of the sac. Among the latter attention may be called to 
 the occasional presence of the vermiform appendix in the sac, with the 
 possibility of appendicitis. Ohsirudion of a hernia is said to occur 
 when the normal course of gas or feces through the herniated bowel is 
 interrupted ; this may result from intestinal indigestion with accumu- 
 lation of flatus, or from fecal impaction (p. 889). The symptoms of 
 inflamed and obstructed hernia are much the same, consisting in 
 local pain, tenderness, nausea, and perhaps vomiting; the hernia still 
 gives an impulse on coughing; and flatus is passed by the anus, though 
 there may be constipation. The symptoms are decidedly less severe 
 than in the case of strangulation. 
 
 Treatment. — The patient should be put to bed, and should lie in a 
 position which relaxes the hernial orifice; an ice bag should be applied 
 locally; an enema should be administered; nothing ichatever should 
 be given by mouth; and if the symptoms are severe or if they do not 
 subside in the course of a few hours, operation, as in cases of stran.- 
 gulation, becomes imperative. In any case where the condition of 
 strangulation cannot be positively excluded, immediate operation 
 should be done. 
 
STRANGULATED HERNIA TCI 
 
 Incarcerated Hernia. — This is one wliicli, th()ii<^li ordinarily re- 
 (lii(il)le, lias tor some reason become temporarily irredncihle (l)e 
 (iarmo). This eomplieation occurs most often in larj^e herniie, and 
 usually is due to unskilful attempts at reduction, resulting? in some 
 slight twist in the howel which renders the hernial orifice relatively 
 too small to allow reduction. Wiiile there may l)e some local pain 
 and tenderness, there are no symptoms of stranj^ulation present. 
 
 Treatment. — Treatment consists in rest in bed, with the foot of the 
 bed elevated and the ])atient so ])laced as to relax the hernial orifice. 
 An ice bag or cold coil should be applied to the hernia, and the surgeon 
 should not attempt to reduce the hernia until the acute symptoms 
 have had a chance to subside; he maj^ find then that the hernia has 
 been spontaneously reduced, or that its reduction })y taxis (p. 760) is 
 easy. If the symptoms do not subside within a few hours, taxis should 
 be tried, and if this fails, operation should be done as in cases of 
 strangulated hernia. 
 
 Strangulated Hernia. — This is one in which the circulation of blood 
 is obstructed or entirely arrested. This serious occurrence is lial)le 
 to bring on all the usual consequences of strangulation, which are 
 studied at p. 762. 
 
 The cause of strangulation of a hernia is not always evident. It 
 is clear that a constriction exists, pressing upon the protruded struc- 
 tures and interfering with their circulation. This constriction may be 
 either in the sac wall, in the surrounding structures, or inside of the 
 sac. Constriction by the sac itself is rare, especially' in children; the 
 site of constriction usually is at the neck of the sac, particularly in 
 the case of patients who have long worn a truss and in whom the sac 
 and its neck have undergone cicatricial contraction. In some cases of 
 congenital sacs points of constriction may exist elsewhere than at the 
 neck (Fig. 780) ; and in some cases constriction may occur from bands 
 of inflammatory adhesions formed within the sac. Extra-saccular 
 constriction is by far the most frequent form and usually occurs at the 
 abdominal opening in fascial or tendinous tissue through which the 
 sac and its contained viscera pass. Intra-saccular constriction, which 
 is rarest of all, may be due to torsion of the contents of the sac, or to 
 the bowel being caught in an aperture or pocket in the omentum. 
 
 Mechanism of Strangulation. — As the neck of the sac and the abdomi- 
 nal opening through which the hernia passes are not muscular, but 
 fibrous, and hence have no power of active contraction, it is evident 
 that in cases of extra-saccular as in those of intra-saccular constriction 
 the prime cause of strangulation lies in the contents of the sac. If 
 the hernia previously was reducible, these changes in the contents 
 of the sac usually b^gin as the state already described as incarcera- 
 tion of the hernia; in the case of irreducible hernia the first changes 
 usually are those described as inflammation or obstruction of the hernia, 
 and they may be brought on by the unwelcome intrusion into the 
 sac of a coil of gut or a plug of omentum never before present. In 
 some patients a hernia which is suddenly developed becomes stran- 
 
762 HERNIA 
 
 filiated iinmodiately on its first appearance; sucli a strangulation is 
 apt to cause rapid and very serious changes in the contents of the sac. 
 A siniihir chain of events usually occurs when a hernia suddenly pro- 
 trudes into a sac which has long been empty, especially if the use of 
 a truss has caused cicatricial contraction in the neck of the sac. This 
 form of strangulation may he described as ixnde to distinguish it from 
 that of more chronic onset, which usually is i)receded by incarceration, 
 inflammation, or obstruction of the hernia. 
 
 All irreducible hernife are more liable to strangulation than those 
 which are reducible and are retained by a truss. An irreducible 
 umbilical hernia is especially liable to strangulation; and, of all forms, 
 a femoral heniia is most prone to strangulation. Neutral and inci- 
 sional hernise very rarely become strangulated. 
 
 Structural Changes Occurring in Strangulation. — Probably in every 
 case the first change is obstruction of the venous circulation of the 
 contents of the sac; the arterial circulation is less rapidly affected 
 because of the higher blood-pressure in the arteries and their more 
 resistant walls. Arrest of the venous circulation causes the blood to 
 be dammed back into the capillaries while these are still receiving 
 blood from the arterial side. The result is stagnation of the blood, 
 and edema of the extravascular tissues. Almost at once the hernia 
 becomes too large to })e returned through the orifice by which it had 
 escaped. If intestine is strangulated, intestinal obstruction (p. 884) 
 is present as well as strangulation, and usually precedes it. 
 
 Strangnlatiou of bowel causes the rapid outpouring of serum which 
 may distend the sac; it will be greater in amount if the strangulation 
 is very slow in onset than if the entire circulation is arrested immedi- 
 ately. At first this fluid is pale yellow, clear, and sterile, and perhaps 
 should be considered a transudate rather than an effusion; but very 
 soon it becomes inflammatory in character, turning cloudy from the 
 increase in the number of leukocytes present, and often is })loody, 
 and in later stages of strangulation, brownish or black. Bacteria soon 
 penetrate the walls of the obstructed bowel. If the strangulation is 
 not promptly relie\'ed, the bowel, which at first is congested, bright 
 red, soggy, and with its natural lustre but slightly impaired, becofnes 
 purplish or even black in color, and may be covered with patches of 
 inflammatory lymph. Actual gangrene quickly follows: the intestine 
 loses its lustre entirely, and becomes soft, doughy, and grayish black; 
 the peritoneal coat strips easily, the muscular coats are friable, and 
 the bowel is very easily torn. In many cases definite rings of con- 
 striction are found at the points of strangulation: usually the con- 
 striction ring at the distal (anal) end of the strangulated loop is more 
 pronounced than that at the proximal (gastric) end. The bowel 
 below the constriction is nearly normal in appearance, or if anything 
 rather paler than normal and collapsed ; that proximal to the constric- 
 tion is distended, congested, and more nearly resembles the gut which 
 has occupied the hernial sac. When the bowel becomes necrotic, or 
 even before, merely as the result of intestinal obstruction, death from 
 
STRA NdVI.A TKl) II A'/.'A 7.t 
 
 7f)3 
 
 toxemia inav occur. If life is proloii^u'd. the slou^rii may separate 
 from tlie intestine, resulting; in intestinal perforation mto tlie hernial 
 sae, which then hecomes the seat of a fecal abscess. The overlymf^ 
 tissues mav next become inflamed, and in rare instances this fecal 
 abscess has opened spontaneously throiiKb the skin. In many cases 
 septic inflannnation spreads to the peritoneal cavity, and f^'cneral 
 periti)nitis is the cause of death. This may occur from perforation 
 of the bowel at the point of constriction iVh^. 7()7), with escai)e of 
 fecal contents into the peritoneal cavity, or from propajration of milam- 
 ination along the coats of the bowel above the constriction. There 
 may be a volvulus of the intestine leading up to the hernial ring, 
 within the abdominal cavity. 
 
 p,p 767 — Rnecimen of gangrenous small intestine resected in a case of strangulated 
 femoral hernia Sesevfnty-one years; hernia strangulated for two weeks before 
 fperatTonFo^al abscess in sac, bowel ruptured just above proximal constriction. 
 Death twelve hours after operation (spinal anesthesia). Episcopal Hospital. 
 
 If omentum is strangulated there is not much serum eflfused in the 
 sac' The omental veins are found distended, dark blue or black, 
 and perhaps thrombosed. The omental fat becomes pinkish red at 
 first, feels denser than normal, and does not bleed readily if incised; 
 later it becomes gravish white and perhaps necrotic. 
 
 Symptoms of Strangulated Hernia.— In almost every case the patient 
 has had a hernia for some time before it becomes strangulated. Lsually 
 following a muscular strain (perhaps merely a mis-step, exuberant 
 laughter, etc.) a sudden pain is felt at the site of the hernia. It the 
 hernia was not down at the time of the accident, it slips out suddenly, 
 even escaping from under a truss if one was worn. If the hernia was 
 down alreadv at the time of the accident, whether irreducible or not, 
 it feels to the patient as if it had increased in size from the protrusion 
 
764 HERNIA 
 
 of additional bowel or omentum. If the pain is very severe the patient 
 may fall to the ground in a state of shock. The pain is followed very 
 soon by a general abdominal pain which at first is colicky, becomes 
 progressively worse, and which later is constant, not intermittent, 
 // not checked by opiates this pain does not leave the patient until gan- 
 grene has occurred or until the strangulation is relieved. Spontaneous 
 cessation of pain therefore is a bad sign; it is accompanied by a false 
 sense of security, and is soon followed by extreme prostration, and 
 signs of impending death as in cases of intestinal strangulation from 
 other causes. 
 
 If the hernia is an enterocele, the usual symptoms of intestinal 
 obstruction (p. 885) de\elop xevy soon after the occurrence of the 
 strangulation. The initial colicky pain, in almost all cases but not 
 always, is accompanied or followed by nausea and vomiting. The 
 vomiting, which at first is the result of nausea, later becomes typically 
 projectile in type, due not to nausea, but to reversed peristalsis. 
 First the gastric contents are vomited; then bile-stained matter; later 
 the contents of the upper intestine, which is brownish and sour- 
 smelling; and in the final stages true fecal or stercoraceous vomiting 
 may occur. Coincident with these symptoms there is absolute con- 
 stipation, and no flatus is passed by the rectum. An enema may 
 empty the rectum of what was already there or in the sigmoid; but 
 after the lower bowel has been emptied, no further movement can be 
 obtained, and in no case is there passage of flatus. In the case of an 
 epiplocele the symptoms are the same though often less in degree, 
 there being seldom absolute constipation or complete arrest of flatus. 
 
 If the intestinal obstruction is not relieved, peritonitis will develop, 
 with its characteristic symptoms and physical signs (p. 805). Until 
 this event occurs the temperature is not elevated, though the pulse 
 slowly but steadily increases in rapidity. 
 
 Physical examination shows a tender, painful, and tense swelling 
 at the site of the hernia. In the case of a large hernia long irreducible, 
 these signs are not so apparent, but usually it is evident that the 
 swelling is somewhat more tense and painful than before the onset of 
 the symptoms of strangulation. In an omental hernia the swelling is 
 boggy, rather than tense. There is no impulse in a strangulated hernia 
 when the patient coughs. Palpation of the abdomen usually reveals 
 rigidity of the abdominal muscles near the site of the hernia; it is a 
 voluntary rigidity, not like that which results from peritonitis. Auscul- 
 tation of the abdomen detects sounds of borborygmi characteristic 
 of peristalsis; usually these peristaltic noises are exaggerated, and 
 sometimes they may be traced up to the site of obstruction, where 
 they are arrested with a distinct click. 
 
 Diagnosis of Strangulated Hernia. — This depends on recognizing, in 
 addition to the symptoms of intestinal obstruction, the existence of 
 a hernia with the signs characteristic of strangulation. If the latter 
 condition is present, it is not necessary to wait for full development 
 of symptoms of intestinal obstruction before making a diagnosis. I 
 
STRANGULATED HERNIA 7G5 
 
 lia\c st'\or;il times found a guii^rciious patch on tlie b(nvel in cases 
 wliore neither nausea nor vomiting had been present, althougli the 
 strangulation had histed for from six to eiglit hours. In very fat 
 patients it may he impossihk' to detect with certainty a very small 
 hernia. All the usual sites of liernia should he carefully examined, 
 and corresponding parts of the body should l)e comj)ared most dili- 
 gently in obscure cases. A feeling of greater resistance over one hernial 
 ring than at the corrcsj)()nding point on the other side of the body may 
 be the only pliysical sign discernible in a case of partial enterocele 
 (Richter's hernia); but such small herniae may become gangrenous 
 much sooner than larger hernia\ If two hcrriicp, both irreducible, are 
 present, it may be difficult to decide which of the two is strangulated; 
 usually the physical signs (absence of impulse on coughing, greater 
 tension and tenderness in the neck of the strangulated hernia) will be 
 of more aid in such cases than the history and subjective symptoms. 
 An irreducible hernia may be present and there may be ijeritonitis 
 from some other cause. The distinctions between intestinal obstruc- 
 tion and peritonitis cannot be too often insisted upon; they are detailed 
 at p. S09. In strangulated hernia peritonitis is a late symptom, all 
 the early signs indicating intestinal obstruction. There may be an 
 irreducible hernia and yet there may be some other cause for intestinal 
 obstruction: here again physical examination will show an impulse on 
 coughing unless the hernia is strangulated; while a careful history of 
 the case may throw much light on the diagnosis as it may indicate 
 previous attacks of peritonitis, leaving crippling bands or adhesions 
 as the true cause of the symptoms. If no conclusion can be reached 
 after careful study, the surgeon should expose the hernia before 
 proceeding to exploratory laparotomy. The vomiting of pregnancy may 
 be confusing, if an irreducible hernia is present; but the negative 
 physical examination of the hernia, and the fact that there is no 
 evidence of intestinal obstruction, should be sufficient evidence of the 
 true condition. In some cases of inguinal hernia, confusion is caused 
 by the presence of an inflamed lymph node in the groin, and in infants 
 by an inflamed, hydrocele of the cord. When, as often in these cases, 
 physical examination is unsatisfactory, and the history is unknown 
 or negative, a differentiation may be impossible. An undescended 
 testicle need not be mistaken for a strangulated hernia if the surgeon 
 is cautious enough to examine the scrotum before reaching a diagnosis. 
 Treatment of Strangulated Hernia. — The object of treatment is to 
 relieve the strangulation. This may be accomplished (1) by pushing 
 the strangulated bowel or omentum back into the abdominal cavity 
 by means of Taxis; or (2) by operation — dividing the constriction, 
 inspecting the bowel, and treating it appropriately before restoring 
 it to the abdomen. In most cases this operation may be completed 
 by repair of the abdominal wall so as to prevent recurrence of the 
 hernia. The physician never should leave his patient until the stran- 
 gulation has been relieved, or until he has made arrangements for 
 immediate surgical treatment. 
 
76G HERNIA 
 
 Taxis. — This is a term derived from tlie (ireek, and implying 
 arrangement or adjustment. It is used in surgery in a technical sense 
 to descril)e various manipulations by which the surgeon seeks to secure 
 reduction of a hernia. The patient should be placed on a bed, with 
 his shoulders and pelvis raised, so as to relax the abdominal muscles. 
 The surgeon then surrounds the hernial orifice with the thumb and 
 fingers of his left hand, while with the right he endeavors by very 
 gentle but persistent compression to empty the herniated bowel of 
 some of its gaseous and fluid contents. When this has been accom- 
 jilished, he employs his right hand in the most gentle and ])atient 
 kneading movements, in the attempt to make the bowel recede into 
 the abdomen. The direction of pressure must correspond to that by 
 which the bowel came down. Success is manifested by the bowel 
 slipping back into the abdomen with an audible gurgle and a charac- 
 teristic flop. If these signs are absent, e^'en though the hernia appears 
 to have been reduced, it is most probable that this is not really the 
 case, but that reduction in 7nass has occurred. This term implies 
 that the contents of the sac have been pushed upward until they lie 
 on the inner aspect of the abdominal wall, but have carried before 
 them the neck of the sac, which is the seat of constriction; and that 
 the hernia, still strangulated, rests between the abdominal wall and 
 parietal peritoneum. If the symptoms of strangulation persist, 
 operation should be done immediately. 
 
 Contraindications to tJie Taxi,^. — ^(1) Taxis never should be employed 
 if anyone else already has attempted it; because there is no telling how 
 much damage may have been done to the gut, and in its present state 
 even the very gentlest manipulation may rupture it or cause other 
 disastrous consequences. (2) Taxis never should be employed in very 
 acute cases; it is suitable only to such as begin with symptoms of 
 incarceration or obstruction of the hernia. (3) Taxis never should be 
 employed while the patient is anesthetized, as there is too much risk 
 of using unjustifiable force. (4) Taxis never should be persisted in 
 for more than fifteen minutes. 
 
 Operation. — The operation for strangulated hernia is one which 
 any medical man may be called on to perform in emergency. It is 
 not nearly so difficult as is the taxis, and is incomparably more efficient 
 in securing the end in view — that of relief of strangulation. If opera- 
 tion were resorted to in every case within the first twelve hours, and 
 with modern aseptic methods, the mortality of strangulated hernia 
 would be only from 3 to 5 per cent., or less than half that of typhoid 
 fever; instead of as high as that of pneumonia, or fracture of the base 
 of the skull, as it is now, when in many cases the obstinacy of the 
 patient or still worse the ignorance of the family physician post- 
 pones operation until gangrene and peritonitis have developed. The 
 mortality when operation is employed under such circumstances 
 varies from 10 to 50 per cent., according to the constitutional resist- 
 ance of the i)atient. If no operation is done, spontaneous cure by 
 sloughing and formation of a fecal fistula may result in as many as 
 2 per cent, of cases, while OS per cent, will terminate in deatii. 
 
STh'.WCCLATKD IIERMA 7C)7 
 
 TIk" operation, wliicli is known as licniiofoiiii/ or ktldtoiiiy, consists 
 essentially in niakinij an incision throuj;h tlie overlying structures 
 until the neck of the sac is exposed; then the sac is opened, and the 
 constriction causinij; stranj^nilation is divided. For this deep incision 
 many surgeons still use Cooper's herniotome (Fig. 7()S) which has the 
 advantages of a l)lunt ])oint which can he sli])ped under the constriction 
 and a short cutting edge. The contents of the sac are then replaced 
 within the abdomen if they are in good condition, and the wound is 
 rej)aired as in an operation undertaken for the "radical cure" of 
 hernia. If the contents of the sac are not in good condition they are 
 treated as descrihed helow (see Treatment of Complications). 
 
 Fig. 768. — C'oopor's horuiotoino. 
 
 In former times, before the days of aseptic surgery, there was great 
 danger of })eritonitis developing after such an operation, and much 
 more stress was laid upon the employment of taxis, and even in 
 operating many surgeons followed the method of Petit (1760), who 
 divided extra-saccular constrictions and then reduced the hernia 
 icithoui opcninc] the sac. But for the last twenty years at least, the 
 taxis has been falling increasingly into disfavor; and especially since 
 the development of methods of inducing local anesthesia, and spinal 
 analgesia, have surgeons been more ready to resort to operation. 
 And I am convinced that it should be clearly understood that no 
 patients however moribund in appearance (unless in articulo mortis) 
 should be refused the hope of recover}' which operation always affords. 
 If the patient is too ill to endure a general anesthetic, and if no facili- 
 ties exist for administering local or spinal anesthesia, there is no reason 
 in the world why the operation should not be done without any 
 anesthetic whatever. Our surgical ancestors operated thus for many 
 generations, and in not an insignificant proportion of cases recovery 
 followed. 
 
 Treat:\iext of Complicatioxs. — As the surgeon cuts through the 
 overlying tissues he may find that they are edematous. This may be 
 the result of trauma inflicted during attempts at taxis, or rarely may 
 be due to inflammation spreading from a fecal abscess in the sac. The 
 sac usually is recognized by its transulucent and bluish appearance. 
 Usually it is impossible, and never is it requisite for the surgeon to 
 recognize the various layers of tissue overlying the sac. Each of the 
 deeper layers as it appears should be cut through cautiously, as one 
 opens the peritoneum, after raising it in forceps from the underlying 
 structures. In this way there is very little danger of injury to the 
 contents of the hernial sac. In most cases there is some fluid in the 
 sac; if it is clear and limpid, it is not likely that the condition of the 
 bowel is very bad. When the sac is opened and the constriction 
 relieved, more of the bowel should be drawn out of the abdomen, and 
 
768 HERNIA 
 
 its condition should be carefully observed. (In serious cases the anes- 
 thetic, if given by inhalation, may be suspended at this point in 
 the operation.) If the bowel was merely nipped in the hernial orifice, 
 and has fallen back into the abdomen as soon as the constriction is 
 relieved, the surgeon never should neglect to draw it out again into 
 the wound to ascertain its condition. The next step is the application 
 to the bowel of hot (115° F.) sterile hot water or saline solution. 
 The hot fluid should not be poured over the bowel with any force, 
 but should be allowed to flow gently over the bowel so as to avoid the 
 trauma even of a current of water. Nor should the bowel be sub- 
 jected to massage or to irritation by gauze sponges. The bowel should 
 be examined for its lustre, its color, and its elasticity. Though the 
 color when first exposed may be bright red, bluish, dark blue, purple, 
 or even black, it may return to normal after relief of the strangulation 
 and application of hot solutions for a varying time up to half an hour. 
 If the gut is entirely gangrenous when first seen, of course it is hope- 
 less to expect its recuperation; but recovery may occur from any 
 stage short of gangrene; and a patch of seeming gangrene which at 
 first appears so large as to demand resection, may be so much dimin- 
 ished in size by hot applications as to permit of retention of the bowel 
 after inversion of the worst portions. If the lustre of the peritoneal 
 coat is preserved, as a rule the color will return to the normal and the 
 bowel will survive. If the mesenteric vessels cannot be felt pulsating 
 the bowel will not survive. If the bowel fills out with its contained 
 air and retains its normal cylindrical form, it is more apt to be healthy 
 than if it has lost its resiliency and retains any indentation or crease 
 accidentally produced during manipulation. Careful inspection 
 should be made also of the circular constrictions on the bowel at the 
 points of strangulation, if such constrictions exist. There may be a 
 threatening perforation here, while the intervening portion of bowel 
 which was not directly compressed, but had its circulation impaired 
 only by pressure on its mesentery, may be fairly normal. 
 
 If the bowel returns to its normal condition, it should be replaced, 
 and the wound should be closed. If a suspected spot remains, it often 
 is possible to cover it in by inverting it and suturing neighboring 
 healthy portions of bowel over it, as indicated in the accompanying 
 diagrams. Even though the entire lumen of the gut appears to be 
 obstructed by the amount of its wall inverted, recovery without any 
 untoward symptom may occur (Fig. 7(39). The sero-sero;us suture 
 is used, as in other intestinal operations (p. 830). If the circular 
 constriction at the point of strangulation has been very tight, it will 
 have crushed all the coats of the bowel except the peritoneum at this 
 point, just as if a compression forceps had been applied to the gut 
 previous to the application of a ligature. In such circumstances the 
 ring of constriction sometimes may be covered in by producing a 
 partial intussusception of the bowel (Fig. 770). 
 
 Onl}^ if there is actual gangrene is resection desirable; and even in 
 such cases, if the patient's condition is very bad, or if the operator is 
 
STRANGULATED HERNIA 
 
 709 
 
 inexperienced, it will 1)0 c[uite sufficient to leave the gangrenous coil 
 of intestine lying in the sac, after relieving the constriction, and 
 packing sterile gau/e around the bowel, which should then be opened 
 and drained. If the proximal (afferent) bowel is very much distended, 
 or if the strangulation has existed a long time, it always is well to 
 evacuate ihe rouietds of the proximal loop (wliich in such cases are 
 regarded as highly toxic), instead of allowing these contents to pass 
 on down through the intestinal canal, whence absorption may occur, 
 causing increased toxemia. 
 
 Fig. 70!). — Gangrenous spot on bowel 
 (a), inverted into lumen by sutures (b). 
 From a patient in the Episcopal Hospital. 
 Recovery. 
 
 Fig. 770. — Gangrenous area involving 
 nearly whole circumference of bowel (a), 
 successfully treated by producing a partial 
 intussusception (b). Episcopal Hospital. 
 
 ^Miere resection of the bowel is done the surgeon may terminate 
 the operation either by establishing a false anus in the wound, or 
 by completing an intestinal anastomosis. The former should be 
 selected in all cases where a prolongation of the operation is not 
 desirable, unless the site of resection is very high in the intestinal 
 canal. When an anastomosis is done it may be either an end-to-end 
 anastomosis or a lateral anastomosis (p. 833). In these cases no fur- 
 ther prolongation of the operation is desirable, so no attempt at a 
 "radical cure" of the hernia should be made; it is sufficient to close 
 the wound, usually with drainage, in the simplest and most expe- 
 ditious manner. 
 
 The treatment of omentum found in the sac demands a few words of 
 explanation. If there is no serious change in this structure, it may be 
 replaced; but if there is any doubt about its condition, it should be 
 49 
 
770 
 
 HERNIA 
 
 excised, after tyiiifj it oti' where normal by a series of interlocking 
 ligatures, below which it is cut away, leaving a sufficient stump to 
 ensure that the ligatures will not slip. Each ligature should include 
 no more than a pencil's thickness of the omentum, and the omentum 
 should be excised before the ligatures are cut short, so that the sur- 
 geon may use them to hold the omental stump in the wound for careful 
 inspection, to make sure that hemorrhage is controlled. The omental 
 bloodvessels have no muscular coats, and do not retract or contract 
 and allow spontaneous cessation of bleeding. Not unfrequently the 
 omentum protrudes in a loop, into the hernial sac (Fig. 771), and unless 
 
 
 Fig. 771. — Loop of omentum protruding into hernial sac, but having its free end 
 within the abdominal cavity. Complications might ensue if this free end was not 
 drawn out before Hgating and cutting off the omentum. 
 
 care is taken to pull the end of the loop out of the abdomen before its 
 base is ligated there will be danger of its necrosing and causing peri- 
 tonitis or obstruction later. The omentum is so seldom normal when 
 it has been long in a hernial sac, even if not strangulated, that I believe 
 it is much better to excise it under all circumstances, unless the con- 
 dition of the patient is such as to render any prolongation of the 
 operation unjustifiable. If it is restored to the abdomen it is quite 
 likely to cause subsequent trouble either by adhesions or by favoring 
 recurrence of the hernia (Lucas-Championniere). 
 
 The after-treatment is the same as after other operations for intestinal 
 obstruction. If the wound has not been securely repaired, the patient 
 should be operated on after complete recovery, to obtain a radical 
 cure; or a truss should be worn to prevent reappearance of the hernia. 
 
 SPECIAL HERNI-ffi. ' 
 
 Classification. — There are only three forms of hernia of frequent 
 occurrence; all the others are rare. The most frequent form is the 
 inguinal, which occurs in about 73 per cent, of cases; then comes the 
 femoral, in about 18 per cent, of cases; and lastly the nmbilical, which 
 occurs in about 8.5 per cent, of cases. This leaves about 1 per cent. 
 
EPIGASTRIC HERNIA 771 
 
 f.,r tl„. n,r,T forms (luinl.ar, „l,turat„r. ,-t,-.). 1" /Lis reckoninK 
 Wv T ,K-isi,„ul iKTMi. is not inclu.lo,!. T„ aHor,l a persp«-tus„l 
 tl,rsul.i;.ct to tlu. student, tlKTC is n,. nu,ro s.-rvnoablc class,h,at,on 
 of licrniii than the follov/ing: 
 
 ITeRNLE of the El'KiASTKIC REGION. 
 
 1. Diaphriiuinatio. 
 
 2. F.pi gastric. 
 
 IIeunle of the Mesogastric Region. 
 
 1. WMitral 
 
 2. Incisional— These mjiy occur also m other regions. 
 
 0. I'mbilical. 
 4. Lumbar. 
 
 Hernle of the Hypogastric Region. 
 
 1. Inguinal. 
 
 1. Indirect (or Oblique). 
 
 2. Direct. 
 
 2. Femoral or Crural. 
 
 3. Pelvic. 
 
 1. Anterior— obturator. 
 
 r (1) Perineal. 
 
 2. Inferior < (2) Pudendal. 
 
 t (3) Vaginal. 
 . / (1) Ischiatic. 
 
 3. Posterior! (2) Gluteal. 
 
 These various forms will now be discussed in turn. Diaphragmatic 
 Herniah.. already been considered (p. 751). Internal Hernm is 
 discussed in Chapter XXII. ,, 
 
 Epigastric Hemia.-By this term is understood one or more sma 
 protri'ions, usually of omentum only, occurring in or near the med a^. 
 line of the abdomen (linea alba) between ensiform process and um- 
 bilicus. It is a rare condition, first well studied by Terrier m 1886. 
 A much more frequent abnormality, and one which often is mistaken 
 for a ture hernials the protrusion of small portions of the vrep^n- 
 toneal fat through apertures between the ^rf^^verse fibres of the 
 sheaths of the recti muscles which go to form the linea alba Accord- 
 ing to Tillaux (1894) it is more frequent in men. The patient com- 
 pkins of pain, and on examination a small mass can be felt the size of 
 a ilarble or thereabouts, and generally irreducible. It simulates an 
 
 '^TrtTment.-If the application of firm pressure by adhesive plaster 
 or an abdominal belt does not afford relief tl.e ^fy'TLZhX 
 excised, after exposing and ligating its pedicle. If the Imea alba is 
 carefully sutured there is not apt to be a recurrence. 
 
772 
 
 HERNIA 
 
 Ventral Hernia. — This hernia may occur in any part of the abclomi- 
 nal wall, but does not protrude through one of the usual apertures 
 such as the umbilicus, the inguinal or femoral canals, etc. It is a 
 very rare form of hernia, though by many surgeons it is not distin- 
 guished from incisional hernia (see below). The usual cause is injury 
 resulting in partial rupture of the alxlominal muscles, from a direct 
 blow or merely by muscular strain. In some cases no distinct history 
 of injury can be obtained, the abdominal wall seeming to have yielded 
 spontaneously at the site where the hernia appears (Fig. 772). No 
 true sac exists, the parietal peritoneum merely bulging a little when 
 the patient strains. 
 
 Fig. 772. — Ventral hernia through right olJiciue muscles. 
 Episcopal Hospital. 
 
 (Dr. Neilson's case.) 
 
 Under the heading of ventral hernia may be included also protru- 
 sion due to diastasis of the recti muscles in the mid-line. A slight 
 degree of diastasis is normal above the umbilicus, but pathological 
 diastasis usually is seen in the hypogastric region, and occurs in 
 women who have borne many children and who are emaciated. A 
 similar condition is frequently seen in infants and young children, as 
 a congenital deformity. 
 
 Symptoms. — The s^^mptoms of ventral hernia are a feeling of weak- 
 ness at the site of the protrusion, and dragging sensations within the 
 abdomen. The diagnosis is not difficult, if the possible existence of 
 the condition is remembered. 
 
 Treatment. — Usually symptomatic relief is secured by wearing a 
 firm abdominal belt. In children with diastasis of the recti the use 
 of adhesive plaster strapping as advised in cases of umbilical hernia 
 usually effects a cure. Even in adults the hernia is not liable to com- 
 plications, but if desired the patient can secure permanent relief by 
 an operation as for incisional hernia. 
 
 Incisional Hernia. — This is much more frequent than a true ventral 
 hernia, and receives its name from its development in the cicatrix of 
 an operative incision. One cannot too much insist upon the impor- 
 
INCISinyAL HERNIA 
 
 11?> 
 
 tauoc ol" placiiiii the incision so as to do as little (iainage as possiljle to 
 the structures of the al)(h)niinal wail (see p. 818). Incisional hernia 
 was nnich more t"rc([U(Mit I'ornierly when less care was taken in the 
 repair ot" alxloniinal wounds. An incisional hernia is very rare in a 
 clean wound which is closed completely by tier suture. If the wound 
 is drained, a hernia is much more apt to develop. 
 
 Fig. 773. — Incisioiuil hernia, in scar 
 of operation for appendicitis .seven 
 years ago (incision in right semilunar 
 line). Episcopal Hospital. 
 
 Fig. 774. — Incisional hernia, in scar of 
 operation for typhoid perforation of intes- 
 tine nine years ago (right rectus incision). 
 Two years ago a right inguinal hernia also 
 developed. Age thirty-six years. (Dr. 
 Harte's case.) Episcopal Hospital. 
 
 This form of hernia may be of any size, and if large may cause 
 very great disability. Usually there is no true peritoneal sac, but the 
 abdominal viscera lie in direct contact with fascia or skin, and almost 
 always are closely adherent to their coverings. Owing to this fact 
 
 Fig. 775. — Incisional heinia one year after operatii^n for api^endicitis (right 
 rectus incision). Children's Hospital. 
 
 there is no chance for spontaneous cure even if the hernia is kept 
 reduced by suitable appliances. As the abdominal opening is rela- 
 tively large, strangulation or other lesser complication is rare; though 
 incarceration may occur if the aperture is small. 
 
 The symptoms are the same as in ventral hernia. 
 
774 HERNIA 
 
 Treatment. -If the patient is healthy, operation should he clone. 
 If this is contraindicated, an abdominal belt, as in cases of pendulous 
 abdomen (Fig. 875), may relieve the worst symptoms. When operation 
 is done it should be remembered that the cicatrix is usually very thin 
 and the hernial contents adherent. The surgeon, therefore, begins by 
 an incision at the periphery of the hernia, and opens the abdomen not 
 directly through the old cicatrix, but through healthy tissues above 
 or below or to one side of the hernia. Here there will be no adhe- 
 sions to the parietal peritoneum. The hernial contents are then 
 cautiously dissected free from the overlying abdominal wall, the cica- 
 tricial tissue is excised, and the herniated structures reduced. In 
 cases of very large hernia with many adhesions between the prolapsed 
 intestines and omentum it is not desirable to separate these more 
 than is required to free the different layers of the abdominal wall. 
 Redundant or diseased omentum should be excised. The various 
 layers of the abdominal wall, especially the aponeuroses, should be 
 dissected free, exposing enough of each for accurate suture, and if 
 possible for overlapping. Then the wound should be repaired as a 
 recent abdominal incision (p. 821). The most important layer of the 
 abdominal wall to suture accurately is the anterior sheath of the rectus 
 or the aponeurosis of the external oblique. Hemostasis should be 
 absolute, and the wound should not be drained. The patient should 
 remain in bed for at least three weeks, and if the hernia was large 
 should wear an abdominal belt and avoid straining efforts for a year 
 after operation. Bartlett (1903) and other surgeons have implanted 
 silver wire filigree in these wounds, with a view of rendering them 
 stronger. Recent experience has shown that free flaps of fascia lata 
 can be transplanted to supply the defect. 
 
 Umbilical Hernia. — This is a frequent affection, especially in 
 infants and stout adults past middle life. Three forms are to be 
 distinguished, the Congenital, the Infantile, and the Adult. 
 
 Congenital Umbilical Hernia is rare, occurring once in five or six 
 thousand births. It is classed as embryonic and fetal. The former is 
 due to failure of development of the abdominal wall, and the hernia, 
 or rather eventration, may be very extensive, containing beside 
 intestine also stomach, liver, heart, etc. The fetal variety develops 
 after the third month of intra-uterine life, and the sac is lined by 
 peritoneum and seldom is very large. Infants with large embryonic 
 hernia usually are stillborn, or die so soon after birth as to offer little 
 chance for repair of the defect by surgical means. The smaller fetal 
 hernia usually is covered only by a translucent membrane through 
 which the herniated viscera can be seen. Other malformations, espe- 
 cially of the bladder or rectum, may be present. 
 
 Treatment. — ^The hernia should be repaired by operation so soon as 
 possible. The general mortality is about 30 per cent., but is less after 
 operation done on the first day of life than later. 
 
 Umbilical Hernia in Infants and Children is very frequent. It develops 
 at any time after complete cicatrization of the navel, and seldom 
 
UMBILICAL UKHNIA i <•) 
 
 appears fir.st after the close of the seeuiicl year of life. I'he hernia 
 seldom is very large, is covered by normal skin, and usually appears 
 not directly under the umbilical cicatrix, but slightly above and to 
 one siile. Pressure by a finger reduces the hernia easily, and when 
 the child cries or strains it becomes larger and more tense (Fig. TTb). 
 Treatment. — If the hernia is small and the child is young, there 
 is some chance of cure without operation. With the child lying down, 
 one end of a strip of adhesive i)laster, about two inches wide is fixed 
 in one lumbar region; then the surgeon draws the opposite side of the 
 belly forward, so as to form a longitudinal fold in the region of the 
 
 
 
 Fig. 776. 
 rachitic negro 
 Hospital. 
 
 Umbilical hernia in a 
 boy. Children's 
 
 Fig. 777. — Result of operation for umbilical 
 hernia with preservation of the navel. Children's 
 Hospital. 
 
 linea alba. The adhesive plaster is then drawn across the relaxed 
 belly and is tightly applied to the loin on the other side. It is well 
 to reinforce this first strip by one or two others. It is better not to 
 place a button, or a coin, or pad, or anything else over the hernia, as 
 these tend to keep open the hernial ring. The adhesive plaster should 
 be renewed about once a week, or as often as it comes loose. Care 
 must be taken to keep the hernia reduced by the finger while the 
 plaster is being changed. Attention is necessary to prevent excoria- 
 tions of the skin. If the plaster is applied too tightly it may encourage 
 the development of inguinal hernia. If this method of strapping an 
 
776 
 
 HERNIA 
 
 umbilical hernia is faithfully continued for a year, a cure will result 
 in a large number of cases if the hernia is small and of short duration. 
 If no improvement is apparent within four or six months, operation 
 probably will be necessary. 
 
 Operation for infantile umbilical hernia is best done after the child 
 is two years old. This will allow a fair trial of conservative treatment. 
 I think it is well in children, especially in boys who are exposed more 
 than girls to ridicule for any abnormality, to do an operation which 
 permits preservation of the riavel, as advised by Stone. I make a semi- 
 lunar incision, below the umbilicus, in the direction of the folds of the 
 skin, and turn this skin flap upward, exposing the hernial ring, which 
 is treated as in adults; when the skin flap is replaced, the patient's 
 aspect is quite normal (Fig. 777). 
 
 Fig. 778. — Umbilical hernia in adult. Age fifty-two years; duration two years. 
 Episcopal Hospital. 
 
 Umbilical Hernia in Adults. — This may be a sequel or recurrence of 
 the infantile form, or may dexelop first in adult life. It is more fre- 
 quent in women, being predisposed to by repeated pregnancies. As 
 in infants and children, the protrusion usually occurs slightly above 
 the umbilical cicatrix. Omentum is almost always present in the 
 sac, and generally becomes adherent, rendering the hernia irreducible 
 at least in part. When the hernia is allowed to grow large, it becomes 
 pendulous (Fig. 778), and usually contains transverse colon and often 
 small intestine also. Incarceration is frequent, and strangulation not 
 unusual. Strangulation often is intra-saccular, a coil of gut being 
 caught in the matted and hypertrophied omentum. The coverings 
 of the hernia are skin, subcutaneous fat, a thin layer of fascia, pre- 
 peritoneal fat, and peritoneum; the latter forms the sac, which is 
 acquired, not congenital. The pressure of the hernia causes atrophy 
 of the tissues overlying it, and the contents of the sac usually lie very 
 close to the skin, at least over the fundus of the sac. In most cases 
 there is also considerable diastasis of the recti muscles, both above 
 and below the ring. 
 
UMBILICAL HERNIA 777 
 
 Treatment. — The best treiitnient is hy operution. Before tliis is 
 attempted, however, it is very important to secure reduction of as 
 mucli of the liernia as is ])()ssil)le, by tlie means described at p. 7()(). 
 
 A transverse incision is made, outlining an ellipse of the redundant 
 skin, including the umbilicus. This incision should extend from one 
 semilunar line to the other, and in very fat patients may have to be 
 even longer. This incision exposes the anterior sheaths of the recti 
 muscles on all sides of the hernial ring, and at some distance from it. 
 The fat is then dissected off the aponeurosis up to the borders of the 
 ring, and at this point the sac is cautiously opened, with the usual 
 precautions against wounding its contents. This is very hard to 
 avoid, if an attempt is made to open the sac at its fundus. The sac 
 is then cut away with scissors at the margins of the hernial ring, on 
 the finger as a guide, and the parietal peritoneum as cut is caught in 
 clamps to prevent it from retracting out of sight. The reducible con- 
 tents of the sac are then replaced in the abdomen. I^sually a good deal 
 of omentum has to be excised; this should be done with the precau- 
 tions recommended at p. 769. The skin containing the umbilicus, 
 circumscribed by the original incision is removed in one piece with the 
 hernial sac {Omphalectomy). When all the hernial contents have 
 been replaced, a gauze pack is inserted to plug the opening and keep 
 them from protruding again. The next step is closure of the hernial 
 ring: a transverse incision is made outward for about one inch from the 
 hernial ring through the anterior sheath of each rectus muscle. Usually 
 there is diastasis of these muscles, and for a distance of one inch or 
 more on each side of the mid-line the anterior and posterior sheaths 
 of the recti may be in contact. The anterior sheaths alone are to be 
 incised, and are dissected upward and downward until a flap of this 
 strong aponeurosis is formed both above and below the hernial open- 
 ing. The margins of the neck of the hernial sac (parietal peritoneum), 
 still caught in forceps, are next to be closed with sutures. This may 
 be accomplished by applying a purse-string (p. 829) if the ring is small; 
 but if it is large it is better to use interrupted sutures. The sutures 
 should include also the transversalis fascia and the posterior sheaths 
 of the recti muscles. Before the last suture is tied the gauze pack is 
 removed. The peritoneal cavity being thus closed, the surgeon catches 
 in Allis forceps the free margins of his aponeurotic flaps already 
 formed from the anterior sheaths of the recti muscles. These flaps 
 are then overlapped, the lower one being pulled up between the 
 upper flap and the deeper structures, and they are sutured together 
 by interrupted mattress sutures of chromic catgut, as indicated in 
 Fig. 779. The free margin of the upper flap may then be sutured to 
 the superficial surface of the anterior rectal sheaths. 
 
 Transverse suture of the wound in repair of umbilical hernia is 
 preferable to longitudinal suture because patients with umbilical 
 hernia usually have quite a pendulous abdomen, and there is much 
 more slack in the tissues and less tension on the sutures if transverse 
 suture is adopted. Frequently it is very difficult if not impossible to 
 
778 
 
 HEHMA 
 
 liring together the edges of the recti by a longitudinal suture, because 
 of their diastasis; but if the transverse suture with overlapping is 
 employed the approximation of the recti is unnecessary. The principle 
 of overlapping fascial layers in the repair of hernia, first introduced 
 in 1881 by Lucas-Championniere, was adopted by W. J. Mayo (1899) 
 in the case of umbilical hernia, and the operation as above described 
 is known by his name. He has since adopted modifications of the 
 technique introduced by Ochsner: no attempt is made to suture the 
 neck of the sac separately, nor are transverse incisions made in the 
 rectus sheaths for the purpose of forming fascial flaps. The opening 
 in the abdomen is closed simply by three mattress sutures so intro- 
 duced as to draw its lower margin well up beneath its upper. I have 
 
 Fig. 779. — Radical repair of umbilical hernia. The parietal peritoneum has been 
 sutured, and the lower aponeurotic flap (anterior sheaths of the recti muscles) is being 
 drawn up underneath the upper flap by means of mattress sutures. 
 
 always used the original method, and believe it is preferable except 
 where the hernial orifice is quite small. The patient should be confined 
 to bed at least for three weeks; and if the hernia was very large or the 
 abdomen very pendulous, an abdominal belt should be v.'orn for several 
 months. Recurrence is very unusual. 
 
 Strangulated Umbilical Hernia. — This is a very serious condition; 
 the patient frequently is old, feeble, asthmatic, fat, and arterio- 
 sclerotic. The hernia in most cases is already irreducible; strangula- 
 tion usually begins with symptoms of incarceration, and the develop- 
 ment of complete strangulation is difficult to recognize, owing to the 
 frequency of intra-saccular strangulation. Taxis should not be per- 
 sisted in unless the patient absolutely refuses operation. Operation 
 usually is too long delayed. When done, no attempt should be made 
 
INGUINAL HERNIA 770 
 
 to coinplt'tf tin- procrdiirc l)y ri'pair (if tlif licriiial orifice if tlit- licriiia 
 has been lon^ irreducible, or if the patient's condition is bad. It is 
 sufficient to relieve tlie strangulation, and the herniated structures 
 may be left adherent to the sac, and should not be reduced. 
 
 Lumbar Hernia. — This is (piite rare. The protrusion occurs through 
 I'etits triangle,^ which is bounded below by the crest of the ilium, 
 in front by the external oblique and behind by the latissimuss dorsi 
 nniscle. The fioor of this triangular space is formed l)y the internal 
 oi)li(lue muscle or its posterior ai)oneurosis, whicli is continuous and 
 identical with the lumbar aponeurosis, with which the transversalis 
 muscle and transversalis fascia are here fused (Fig. 916). The cover- 
 ings of the hernia are skin, sui)erficial fascia, lumbar aponeurosis 
 (or internal ol)lique), ])reperitoneal fat, and ])eritoneum. 
 
 Most of the cases of lumbar hernia on record have been either con- 
 genital (probably due to abnormal size of Petit's triangle), or the result 
 of trauma. The condition presents the usual symptoms and physical 
 signs of a reducible hernia (p. 756), and must be distinguished from 
 a cold abscess, as well as from a lipoma. There is no distinct neck to 
 the sac. Strangulation is unusual. 
 
 Treatment. — If the patient wears a well-fitting truss for a \ear or 
 more, there is fair probability that a small hernia may cease to pro- 
 trude. In most cases, however, operative treatment is preferable. 
 This consists in dissecting out the layers of the abdominal wall, and 
 overlapping them by sutm"e whenever this is possible. Dowd (1907) 
 turned up a flap from the fascia lata covering the gluteal region, 
 to aid in closure of the opening. 
 
 Inguinal Hernia. — Of the three usual forms of hernia, inguinal, 
 femoral, and umbilical, inguinal hernia is by far the most frequent. 
 It comprises a.bout three-fourths of all cases of hernia, and is much 
 more frequent in men than in women. In males, 9() per cent, of 
 hernias are inguinal, about 2.5 per cent, are femoral, and only 1 per 
 cent, are umbilical. In females, 50 per cent, are inguinal, 33 per cent, 
 are femoral, and 16 per cent, are umbilical (De Garmo). 
 
 Nomenclature. — If the hernia emerges from the peritoneal cavity 
 at the internal abdominal ring, traverses the inguinal canal, and ap- 
 pears at the external abdominal ring, it is called an indireci or oblique 
 inguinal hernia. If it passes directly through the abdominal wall on 
 the median side of the deep epigastric artery, and thus appears at the 
 external ring without traversing the inguinal canal, it is called a direct 
 inguinal hernia. This is much rarer than the indirect form. If the 
 hernia remains above the brim of the pelvis, it is called an incomplete 
 inguinal hernia, or a bubonocele; if it descends beyond the brim of the 
 pelvis it is called a complete inguinal hernia. A complete inguinal 
 hernia in the male enters the scrotum and is termed a scrotal hernia; 
 in the female it enters the labium majus and is called a labial hernia 
 (this should not be confused with a pudendal hernia, p. 800). 
 
 1 Lumbar hernia was first described by J. L. Petit in 1783. 
 
rso 
 
 HERXIA 
 
 Oblique Inguinal Hernia. — Inguinal hernia is more frequent in the 
 male because of the greater size of the inguinal canal and because of 
 the existence of the vaginal process of peritoneum which accompanies 
 the testicle in its descent into the scrotum. These facts account also 
 
 Fig. 780. — Incomplete obliteration of 
 the funicular process of peritoneum, just 
 above the testicle. Found at operation on 
 a patient aged thirty-two years; duration 
 of hernia sixteen years. Episcopal Hos- 
 pital. 
 
 Fig. 781. — Ordinary adult type of in- 
 guino-scrotal hernia: fundus of sac 
 separate from testicle, and easily enu- 
 cleated. Hernia usually slowly de- 
 veloped. 
 
 for the greater frequency of oblique than of direct inguinal hernia. 
 It is gradually coming to be recognized, largely owing to the teaching 
 of Hamilton Russell (since 1899), and of R. W. ^Murray, that most 
 
 Fig. 782. — Hernia into patulous pro- 
 cessus vaginalis: there is no separate 
 tunica vaginalis. So-called "congenital 
 hernia. " A hernia of sudden formation. 
 
 Fig. 78.3. — Hernia into funicular pro- 
 cess: fundus of sac adherent to tunica 
 vaginalis. So-called "infantile hernia." 
 A hernia of sudden formation. 
 
 cases of hernia are due to the existence of a preformed sac. The proba- 
 bility of the existence of such a sac is greatest in the inguinal region; 
 and formerly it was the custom in describing oblique inguinal hernia 
 to lav great stress on the different varieties of sac which might be 
 
INGUINAL HERNIA 
 
 781 
 
 present, aeeordiiig to tlie stage of development which had been reached 
 by the vaginal process of peritoneum during fetal Hfe. These dis- 
 tinctions have little more than academic interest; but a reference to 
 the acconii)an\ int,^ illustrations will explain the five forms which may 
 be encountered. Occasionally iiicoiiijjlrir ohlitenifidn of the Jiininildr 
 process occurs at one or more i)oints, forming fibrous bands or strictures 
 in the serous sac (Fig. 780) ; this accounts for cases of bilocular hydro- 
 cele (p. 1000), and is of some imi)ortance because strangulation may 
 occur at any of these i)oints, as well as at the neck of the hernial sac. 
 The fact of greatest imi)ortancc to bear in mind is that it is the exist- 
 ence of a preformed sac which predisposes to development of hernia, 
 and that it is the extirpation of tJie sac which is the most important step 
 (especially in cliildren and young adults) in the operation for the cure 
 of hernia. A. II. Ferguson pointed out that in some patients the 
 
 Fig. 784. — -Hernia encysted into the 
 tunica vaginalis. The "encysted hernia 
 of Sir Astley Copper." Funicular process 
 closed only at the internal ring. An ac- 
 quired hernia of slow formation. 
 
 Fig. 78.5. — Hernia encysted between 
 tunica vaginalis and testicle. "Encj^sted 
 hernia of Hey, of Leeds." Due to same 
 congenital defect as Fig. 784, but parietal 
 peritoneum has yielded just posterior to 
 upper obliterated end of funicular process. 
 
 internal oblique muscle does not have an origin from Poupart's 
 ligament, as is normally the case, and that this renders the region of 
 the internal abdominal ring very weak. Apart from these anatomical 
 factors, the predisposing and exciting causes of inguinal hernia are 
 the same as those of hernia in general (p. 754). 
 
 If the hernia is present at birth it is one usually described as congenital 
 (Fig. 782); but of course a "congenital" sac may be present but no 
 hernia develop until adult life. If the hernia appears at any time 
 after birth, and is of sudden formation, it is probable that there was a 
 preformed sac, and that the sudden appearance of the hernia is caused 
 by muscular effort forcing some of the abdominal contents into this 
 sac (Fig. 783.) If the hernia is of slow formation, which is rare except 
 in adults, it is still possible that a small preformed sac may have 
 existed. 
 
782 
 
 HERNIA 
 
 If the hernia occurs into a sac formed by the patulous vaginal 
 process of peritoneum (Fig. 782), whether the hernia is present at 
 birth, appears during infancy or childhood, or does not appear until 
 
 Fig. 76(5. — Kight oblique inguino- 
 scrotal hernia. Congenital sac, but hernia 
 developed in adult life. Outline of testi- 
 cle obscured. (See Fig. 782.) Episcopal 
 Hospital. 
 
 Fig. 7n7. — Right oblique inguino- 
 scrotal hernia, funicular type (infan- 
 tile). Age sixteen years. Outline of 
 testicle distinct from that of hernia. 
 (See Fig. 783.) Episcopal Hospital. 
 
 late adult life, the contents of the hernia ivill obscure the outline of the 
 testicle (Fig. 786). If, however, the testicle has its own tunica vagi- 
 
 -:^- 
 
 FiG. 788. — Right oblique inguino-scrotal hernia; age sixteen years; slowly acquired 
 three years ago. McBurney incision for appendicitis eight years ago. (See p. 754.) 
 Outline of testicle distinct from that of hernia. (See Figs. 781 and 791.) Episcopal 
 Hospital. 
 
 nalis (Figs. 781 and 783), the hernia and the testicle can he perceived as 
 separate swellings in the scrotum (Figs. 787 and 788). This distinction 
 is of some clinical importance, when operative treatment is under- 
 
INGUINAL HERNIA 783 
 
 takfii (\). "Sltj. In all cast's, with wry tVw (.'xc('j)ti()iis, the hernia lies 
 in front of the spermatic cord, and even if the hernia is irreducible, 
 the cord usually can be palpated behind it. 
 
 Symptoms and Diacnosis. — An ()l)li([U(' in<i;uinal hernia is more 
 common on the ri}i;ht side. It appears first at the internal abdominal 
 riu^, and may or may not descend into the scrotum. In its descent 
 it always j^asses through the inguinal canal. The longer its duration 
 and the larger the hernia, the less oblique becomes its pas.sage 
 through the abdominal wall, as the internal ring gradually enlarges 
 and shifts its position nearer to the spine of the pubis. When in the 
 scrotum the hernia is not attached to the testicle, and in most cases 
 can be reduced within the abdomen. This reduction is attended by 
 characteristic signs (p. 757). If the hernia is irreducible the diagnosis 
 may be more difficult; but always, unless strangulated, the hernia 
 transmits an impulse when the patient coughs. The differential diag- 
 nosis of direct inguinal hernia is considered at p. 792, and that of 
 femoral hernia at p. 794. 
 
 An incomplete hujmnaJ hernia must be distinguished from: (1) 
 Hydrocele of the cord (p. lOGO). If this is inflamed, it may closel}^ 
 resemble a strangulated inguinal hernia, unless a clear history can be 
 obtained. But there are no signs of intestinal obstruction. (2) 
 Inflammatory Lymphadenitis, or Inguinal Bubo (p. 269), is inflam- 
 matory in nature, is irreducible; gives no impulse on coughing; and 
 usually a source of infection in the genitals, lower extremity, or buttocks 
 can be found. (3) Tuberculosis of the Inguinal Lymph Nodes may 
 resemble an irreducible epiplocele ; but there is no impulse on coughing ; 
 the history of the onset of the two affections is different; the swelling 
 lies superficial to the inguinal canal, and does not extend into the 
 scrotum even if of long duration; suppuration is frequent. (4) Cold 
 Abscess, the result of tuberculosis of the spine, occasionally makes 
 its appearance in the inguinal canal ; it may transmit an impulse when 
 the patient coughs, and often is reducible when he lies down; but the 
 abscess presents no gurgling on reduction, and it is dull on percussion, 
 which an enterocele is not ; moreover, examination of the spine usually 
 will reveal the true condition. (5) Undescended Testicle (p. 1050). 
 This is recognized because the scrotum on the affected side is empty, 
 and because of the sickening pain produced by handling the tumor, 
 which is irreducible. 
 
 A complete inguinal hernia must be distinguished from: (1) Vaginal 
 Hydrocele, (p. 1059), which appears first, not at the internal abdominal 
 ring, but in the scrotum ; which rarely extends into the inguinal canal ; 
 which is attached to the testicle and is irreducible; which though cystic 
 on palpation is dull, not resonant, on percussion, and which transmits 
 light. (2) Congenital Hydrocele (p. 1058); this may be distinguished 
 from a hernia because the inguinal canal seems empty except for the 
 cord; because when reduction occurs there is no gurgling or flop of 
 intestine; because of the extreme slowness w'ith which the scrotum 
 refills wdien the patient stands up; and because the hydrocele is dull 
 
784 
 
 HERNIA 
 
 on percussion and is translucent. (.3) Varicocele {\i. 1061). This 
 appears first in the scrotinn, not at the internal abdominal ring; it 
 may not extend into the inguinal canal; it gives a xevy different 
 impression from a hernia when palpated; and though usually the 
 swelling disappears when the patient lies down and the scrotum is 
 elevated, this occurrence is not attended by any of the signs which 
 indicate the reduction of a hernia. (4) Sarcocele (p. 1056). This is 
 formed by an enlargement of the testicle itself; it appears first in the 
 scrotum; is irreducible; is dull on percussion even if partly cystic; 
 and though thickening of the spermatic cord may occur from extension 
 of the disease, this does not present the characteristics of a hernia. 
 Oblique Inguinal Hernia in the Female. — In women only the round 
 ligament passes through the inguinal canal. It carries with it a 
 
 process of peritoneum (the canal of 
 Niick), which may remain patulous 
 and predisposes to the formation of 
 a hernia. The internal oblique 
 muscle in the female, as a rule, 
 has a larger origin from Poupart's 
 ligament than in the male, and no 
 doubt this lends additional strength 
 to the region of the internal ab- 
 dominal ring and the inguinal canal. 
 In children a hernia usually is ar- 
 rested in the canal of Nuck (Fig. 
 789), but in adults it often descends 
 into the labium majus, though 
 rarely attaining very large size. 
 
 Strangulation of Oblique Inguinal 
 
 Hernia may occur in the neck of the 
 
 sac, at the internal ring, or at 
 
 the external ring. The external ring 
 
 should be divided first whenever strangulation is present; the sac is 
 
 then opened; and if strangulation is not relieved by this means, the 
 
 neck of the sac and the internal ring must be divided also. 
 
 Rare Forms of Oblique Inguinal Hernia. — A hernia may make its 
 appearance at the internal abdominal ring, but for some reason be 
 arrested in its journey downward to the scrotum. This may be due 
 to the obstruction offered by an undescended testicle (occasionally 
 an ovary in the female), or from the partial constrictions in the lumen 
 of a preformed sac, to which reference was made at p. 781. (1) If 
 the hernia is arrested just outside of the internal abdominal ring and 
 forms for itself a di^'erticulum out of the sac wall, between the parietal 
 peritoneum and the abdominal muscles, it is called an inguinal pro- 
 per itojieal hernia (first well described by Kronlein in 1880). This 
 hernia usually spreads toward the median line of the body. (2) If 
 it forms a sac for itself between the muscular planes of the abdominal 
 wall it is called an interstitial or interparietal hernia; this is the least 
 
 Fig. 789. — Double oblique inguinal 
 hernia into the canal of Xuck, in a girl 
 of nine years. Children's Hospital. 
 
INGUINAL HERNIA 
 
 785 
 
 unusual foriu, and tlu- lu-rnia ^a-ncrally spreads outward toward tlic 
 cTfst of tlu' ilium. {'A) If the hernia occupies a diverticulum in the 
 suhcutaneous tissues, outside of the external ahdoniinal rin^^ upon 
 Poupart's li};ament, or overhanging the upi)er i)art of Scarpa's triangle, 
 it is known as a superficial inguinal hernia or an inguinu-crural hernia; 
 this is the rarest of these unusual forms of hernia. 
 
 These hvTu'nxi are very liable to strangulation, hut the exact diagnosis 
 of the condition seldom is made hcfore operation. 
 
 Unusual Contents of Oblique Inguinal Hernia. The usual contenU 
 are small howel and omentum. The presence of large bowel is unusual. 
 When i)resent it usually forms what is " 
 known as a sliding hernia, as the bowel 
 usually slides down retroi)eritoneally, 
 carrying a peritoneal pouch down with 
 it, covering only its anterior aspect. In 
 this pouch small bowel and omentum 
 may be contained, and when these are 
 reduced at operation, the surgeon will 
 find that the posterior wall of the her- 
 nial sac covers the large bowel (Fig. 
 790). A sigmoid hernia, occurring on 
 the left, is considered more frequent 
 than a cecal hernia on the right. Occa- 
 sionally a cecal hernia occurs on the 
 left; in such cases it is probable that 
 the cecum has been drawn into the sac 
 by the traction of the ileum already in 
 the sac. The presence of the vermi- 
 form appendix in the hernial sac is of 
 
 considerable importance, as it may become the seat of acute inflam- 
 mation, gangrene, etc. Such cases have been carefully studied by 
 Jacquemin (1905) and by IMassoulard (1906). An undescended testicle 
 usually is accompanied by a hernial sac; this subject is discussed at 
 p. 1050. Occasionally in the female the ovary, the tube, or even the 
 uterus (pregnant or non-pregnant) is found in the sac of an inguinal 
 hernia; F. T. Andrews (1905) has tabulated 366 cases of this nature. 
 Treatment of Oblique Inguinal Hernia in Adults. — A cure 
 without operation is all but unknown in adult patients. The mor- 
 tality of the operation is very low, scarcely one in three or four hundred 
 cases; and the deaths scarcely ever are due to the operation itself, but 
 to complications, which may follow any operation. Recurrence of 
 the hernia takes place in very few cases; according to Coley, permanent 
 cure is effected by proper operation in about 95 per cent, of cases. 
 But w^hen for any reason operation is contraindicated, or when the 
 patient refuses operative treatment, the surgeon should know what 
 measure of relief may be effected by mechanical treatment, and should 
 be able to order intelligently the proper form of truss, and to see that 
 it accomplishes the purpose for which it is designed. 
 50 
 
 Fig. 790. — Slidins hernia of the 
 cecum: small intestine in the her- 
 nial sac. Age thirty-one years; 
 duration two years. Episcopal 
 Hospital. 
 
786 
 
 HERNIA 
 
 Trusses for hnjuinal Hernia.- — The ])ad of the truss is to bo ap[)lie(l 
 over the inguinal canal, so as to hold its superficial and deep walls 
 in contact, and thus to close the channel by which the hernia descends. 
 The pad must not be placed only over the external ring, still less over 
 the spine of the pubis, as this allows the hernia to slide past the truss 
 (Fig. 791). The pad should not be set at an angle with the spring of 
 the truss (as in the bad type of truss introduced in 1837 by Dr. Heber 
 Chase, and still in use), but should be directly beneath the spring, so 
 as to ensure its remaining in place and exerting direct pressure on the 
 canal. The counterpressure is over the sacral region or the pos- 
 terior part of the buttock of the opposite side, just lateral to the 
 posterior superior spine of the ilium. In young adults, where the 
 hernia is small and easily retained, the cross-body truss (Fig. 792) is 
 the most serviceable type. According to De Garmo this type was 
 introduced by an English firm of instrument-makers toward the 
 
 Fig. 791. — Badly fitting truss of French-German type. Pad is placed over spine of 
 pubis, and the hernia is now in the scrotum. Same patient as Fig. 788. Has worn 
 truss this way more than two years, in hope of being cured. Episcopal Hospital. 
 
 close of the eighteenth century. The spring is complete in front; 
 beginning at the pad over the inguinal canal, it passes across the 
 pubis from the affected to the unaffected side, and is continued around 
 three-fourths of the pelvis to the buttock of the affected side. The 
 strap holding the ends of the spring together thus lies on the same side 
 of the pelvis as the hernia. The pressure made by the pad is inward 
 and slightly upward. If the hernia is less easily retained, or if the 
 patient is older and obsese, a truss with double pads gives better sup- 
 port; the best is the Hood type of truss, introduced about seventy 
 years ago by Dr. J. W. Hood, of Kentucky. The spring is solid in 
 front, and supports adjustable pads, one over each inguinal canal 
 (Fig. 793), and is continued posteriorly on each side to within a few 
 inches of the spine, where it is supplied with two pads for counter- 
 pressure; the ends of the spring are connected across the spine by a 
 short strap. This is also the best type of truss for double inguinal 
 
INGUINAL HERNIA 
 
 787 
 
 hernia. Tlie truss is so secure that very Httle elastic spring' pressure is 
 neeiled to keep it in phice and to retain tlie hernia, a fact wiiicli renders 
 it very comf()rtal)le for tlie patient to wear. Otlier forms of truss, 
 the English rat-tail truss, and the French and Ccrnian trusses are 
 much less efficient. 
 
 Fig. 792. — Cross-body truss, fitting 
 well. Age twenty-two years. Appen- 
 dicitis operation (rectus incision) one 
 year ago; hernia developed six months 
 later. Episcopal Hospital. 
 
 Fn,. 7!to. — Double hood truss, applied 
 for large left inguinal hernia; light pad 
 also on right side. Age fifty-nine years. 
 This truss maintains reduction even in 
 severe coughing. Episcopal Hospital. 
 
 Operation for Oblique Ixguixal Hernia. — Almost every sur- 
 geon who operates on many cases of inguinal hernia develops certain 
 modifications of technique peculiar to himself. Many of these have 
 been published as original operations, though few of them are real 
 improvements on the universally accepted t^pe of operation which is 
 that introduced in 1885 by Bassini. This is the best operation for the 
 average case, and if it is well learned the operator can introduce such 
 improvements as suggest themselves in special cases as he increases 
 in experience. It is not often that two cases of hernia are as alike as 
 two peas. 
 
 Bassini' s Operation. — ^The incision runs above and parallel to Pou- 
 part's ligament from the internal to the external abdominal ring. 
 This incision passes at once to the aponeurosis of the external oblique; 
 the deep layer of the superficial facia (Scarpa's fascia) sometimes is 
 mistaken for this aponeurosis. There will be cut in this incision at 
 least two veins — the superficial epigastric and the superficial circum- 
 flex iliac veins. The four bleeding-points should be clamped and 
 ligated. Any other bleeding-points should be clamped and ligated. 
 Every bleeding-point encountered during the operation should be 
 clamped and ligated. It is not suflBcient to trust to forcipressure for 
 permanent hemostasis. The success of the operation depends on the 
 aseptic healing of the wound, and the development of a very small 
 hematoma may nullify the entire work. 
 
788 
 
 HERNIA 
 
 When the aponeurosis is exposed, the external abdominal ring 
 should be identified. If not readily apparent it is easily found by 
 raking upward with the handle of the scalpel in the neighborhood 
 of the pubic spine (Fig. 794). An incision is next made through the 
 external oblique aponeurosis from the region of the internal ring into 
 the external ring; this incision runs parallel to Poupart's ligament 
 and at least half an inch above it. Do not make the incision too near 
 Poupart's ligament or there will be no free margin of the external 
 oblique aponeurosis to facilitate subsequent suture. There is no 
 advantage in not cutting through the pillars of the external ring. 
 
 Fig. 794. — Operation for inguinal hernia: superficial fascia incised and bleeding- 
 point.s located. Aponeurosis of external oblique exposed, and external abdominal ring 
 identified by handle of scalpel. 
 
 ^^^len the external oblique aponeurosis has been incised, its cut 
 margins are retracted, by blunt dissection with the handle of the 
 scalpel, until the inner shelving margin of Poupart's ligament is well 
 exposed below, and the arching fibres of the internal oblique can be 
 easily seen on the upper (umbilical) side of the wound. The ilio- 
 inguinal nerve should not be injured. The index finger is then passed 
 down on the outer side of the inguinal canal, close to Poupart's liga- 
 ment, and hooks up all the structures of the canal, including the 
 hernial sac and the s|>ermatic cord (Fig. 795). By a little skilful dry 
 dissection the end of the finger can be passed entirely through, 
 beneath these structures from the lower to the upper side of the 
 wound. Holding these structures upon the left index finger, the sur- 
 geon strips its various coverings off the hernial sac by wiping them 
 away with gauze or by the use of dissecting forceps. As little cutting 
 as possible should be done, as this increases' bleeding. The names of 
 these deep coverings of the hernia (intercolumnar fascia, i. e., external 
 oblique; cremasteric fascia, i. e., internal oblique, and fascia propria 
 i. e., transversalis fascia, have little more than academic interest. 
 
INGUINAL HERNIA 
 
 789 
 
 The sac is least adlicrcMit to surroiiiKliii},^ structures in the upper part 
 of the iufiuinal eaual, and it is best to isuhite it here first. 
 
 When tlie sac is finally bared, it may be opened, and its contents 
 reduced. Then with one fin<;er inside the sac, the surj^eon proceeds 
 to complete its enucleation from the surroundinff tissues.' The sac 
 sac is separated from the cord, and the dissection is continued upward 
 to the internal ring, until parictdl pcrituneuni is reached. This is known 
 by the presence of pre-peritoneal fat, and by the peritoneum becoming 
 whiter, denser, and more fibrous; and the operator should not be 
 satisfied until such peritoneum has been reached. If he desists before 
 parietal i)erit()neum is reached he will leave the upper part of the sac 
 behind, in the form of a pouch, which will predispose to recurrence. 
 The operation is not always easy. When the parietal peritoneum has 
 
 Fic. 795. — Operation for inguinal hernia: the inguinal canal has been exposed by 
 an incision through the aponeurosis of the external oblique. The finger is passed down 
 close to Poupart's ligament and hooks up all the structures in the canal. 
 
 been exposed, the neck of the sac is closed by a purse-string suture, 
 or if large by continuous suture, as in the case of any abdominal wound. 
 It is not sufficient merely to ligate the sac as one ligates an artery; 
 such a ligature is very apt to slip off the neck of the sac. When the 
 neck of the sac has thus been securely sutured, the sac is cut away, 
 but the ends of the suture are left long; the neck is now allowed to recede 
 into the upper angle of the wound, and is carefully inspected for 
 bleeding; if this is found the neck of the sac is drawn again into full 
 view by the attached suture, and the bleeding-point is ligated or 
 
 1 If the sac is of the "congenital" type (Fig. 782), its complete enucleation is 
 impossible. The fundus should be left attached to the testicle, and may be 
 sutured, to form a tunica vaginalis. If very much of the fundus is left a 
 secondary hydrocele may form. 
 
790 
 
 HERNIA 
 
 controlled by an additional suture. When it has been ascertained that 
 there is no bleeding, the ends of the suture are cut short, and the 
 surgeon proceeds to close the inguinal canal. 
 
 The spermatic cord is held out of the way, and the first row of deep 
 sutures is introduced. These sutures are to approximate the arching 
 fibres of the internal oblique and the conjoined tendon to the inner 
 shelving margin of Poupart's ligament, so as to form a new floor to 
 the inguinal canal, upon which the transplanted cord is to lie. This 
 is the essential feature of Bassini's operation. In passing these sutures 
 there is considerable danger of wounding the femoral vessels, especially 
 the vein, beneath Poupart's ligament. These are mattress sutures of 
 chromic catgut (No. 2 or Xo. 3). The first suture is passed at the 
 upper end of the inguinal canal just below the internal ring. The 
 round-pointed curved needle is entered from the superficial aspect of 
 
 Fig. 796. — Operation for inguinal hernia: suturing the arching fibres of the internal 
 oblique (beneath the cord) to Poupart's ligament. 
 
 Poupart's ligament (Fig. 796), and emerges (on the surgeon's index 
 finger as a guide) on the deep and shelving border of this ligament 
 in the inguinal canal. It is better to prick your finger than to injiu-e 
 the femoral vein. The needle is then passed beneath the spermatic 
 cord, and takes a firm hold of the internal oblique, passing through it 
 from below upward. The course of the needle is then reversed, passing 
 first through the internal oblique from above downward, then across 
 the inguinal canal beneath the cord, and finally through Poupart's 
 ligament from within outward, to emerge about half a centimeter 
 from its original point of entrance. This completes the first mattress 
 suture. Usually three or four other similar sutures are required, the 
 last sutures drawing the conjoined tendon down against the lower 
 and inner end of Poupart's ligament. If the upper end of the canal 
 seems weak, it is well to pass the first suture through Poupart's 
 
IXariXAL IIEliSIA 
 
 701 
 
 Iii;;tiiu'iit and tlic iiitcriial <>l)li(|ii(' just on the lateral (flank) side of the 
 internal rin^. By j)assin,u all these deep sutures as deserihed, the 
 knots are hrouulit entirely outside the inj^Miinal canal, 'i'his is an 
 advantajije. 
 
 The spermatie cord is now replaced on the superficial surface of the 
 internal ohlifpie, and the cut niarj^ins of the external oblique aponeu- 
 rosis are then sutured, over the cord, witli a contiiuious suture (the 
 second row of deep sutures) from above downward, leaving an opening 
 below (the new external ring) just large enough to transmit the cord 
 (Fig. 7i)7). The skin wound is then closed in the usual way. The 
 patient slionld remain in bed two weeks, and if the hernia was large, 
 or if more than one hernia was operated on, for three weeks or longer. 
 
 Fig. 797. — Operation for inguinal hernia: the aponeurosis of the external oblique 
 is sutured over the cord. 
 
 In women the operation is simpler, since there is no cord in the way. 
 The canal may be completel}' closed, the round ligament being included 
 in the sutures. 
 
 In infants the use of a truss for a year or more will cure a small 
 hernia in a fair proportion of cases — De Garmo says in 95 per cent. 
 But this means that the truss fits, that it is changed from time to time 
 as the child grows, that the patient is under constant surgical super- 
 vision, and that the truss is employed with all the precautions enumer- 
 ated at page 759. Unless these conditions are fulfilled, and they 
 rarely are, a cure need not be expected. But, as a rule, it is not desir- 
 able, though perfectly possible, to resort to operation on a child until 
 it has learned to control its bladder and bowels. The youngest patient 
 I have operated on was a boy, six weeks old, with strangulated hernia ; 
 he was not confined to bed after the operation, and did perfectly well. 
 In young children complete extirpation of the sac is sufficient to ensure 
 against recurrence; it is not necessary to transplant the cord, and 
 if it is short it may be impossible to do so. If the inguinal canal seems 
 
792 
 
 HERXIA 
 
 weak, the other steps of the operation are the same as in the Bassini 
 operation. This form of operation, without transplanting the cord, 
 was employed also in adults by A. H. Ferguson (1899), and is known 
 as Ferguson's method. 
 
 Direct Inguinal Hernia. — This hernia is one which protrudes through 
 the abdominal wall on the median side of the deep epigastric artery, 
 just to the outer side of the spine of the pubis, and directly behind 
 the external abdominal ring. This is the space known as Hesselbach's 
 triangle. Direct hernia is seen about once in every 30 to 40 cases of 
 indirect inguinal hernia. It is least rare in adults and occurs oftener 
 
 in men than in women. It is 
 a hernia of slow formation, 
 and there is no well defined 
 neck to the sac. In most cases 
 it may be recognized at a glance 
 (Fig. 798). Strangulation is 
 very unusual. It is distin- 
 guished from oblique inguinal 
 hernia by the fact that when it 
 has been reduced, pressure over 
 the internal abdominal ring 
 does not prevent its reappear- 
 ance. It should not be for- 
 gotten that a large indirect 
 inguinoscrotal hernia may cause 
 the position of the internal ab- 
 dominal ring to shift until it 
 lies directly behind the external 
 ring; but a direct hernia never 
 descends far into the scrotum. 
 Sometimes when the hernia is reduced, it is possible to palpate the 
 deep epigastric artery on the lateral margin of the hernial orifice. 
 If there is any doubt about the nature of the hernia, it probably 
 is an indirect inguinal hernia. 
 
 A direct hernia usually protrudes tlirough the conjoined tendon, 
 which is carried forward as one of its coverings. Occasionally, how- 
 ever, it passes to the outer side of the conjoined tendon. In most 
 cases the spermatic cord lies on the outer side of the sac. 
 
 Rare Forms of Direct Inguinal Hernia. — Sometimes the sac of a direct 
 inguinal hernia occupies (1) a properitoneal position near the bladder; 
 or after protruding tlirough the conjoined tendon on the median side 
 of the obliterated umbilical vein, it may lie (2) between the conjoined 
 tendon and the external oblique aponeurosis, or (3) in a subcutaneous 
 position in front of the external oblique aponeurosis. For these rare 
 varieties of direct inguinal hernia Reich, in 1909, proposed the name of 
 Supravesical Hernia. He collected 16 cases of the first variety, which 
 he calls internal supravesical hernia; and 26 cases of the second and 
 third varieties, which he terms external supravesical hernia. 
 
 Fig. 79S. — Double direct inguinal hernia, 
 age sixty-eight years; duration thirty j-ears. 
 Of slow onset, from constant straining in 
 urination. Has strictures of urethra, and 
 enlarged prostate. Operation on hemiae 
 eontraindicated until urinarj- obstruction is 
 relieved. Episcopal Hospital. 
 
FEMORAL HERNIA 793 
 
 Treatment of Direct Inguinal Hernia. — If a truss is used, it must 
 ha\o a liir^f i)a(l, as the hernia is diflieult to eoutrol. l{ej)air of the 
 defect hy ()i)eration is also more difhcult and is less sure in preventing 
 recurrence than in indirect inj,minal liernia. The parts are exposed 
 in the same way, and the sac is isolated. In doing this the surgeon 
 should remember that the bladder frequently protrudes into Ilessel- 
 baeh's triangle, and that its extraperitoneal surface is with difficulty 
 distinguished from preperitoneal fat. Any fatty mass toward the 
 median side of the liernial orifice should be avoided. When the sac 
 has been opened and its contents have been reduced, it will be found 
 that an opening is left which it is difhcult to suture firmly, owing to 
 the relaxed and atrophied condition of the various layers of the afxlomi- 
 nal wall. After the parietal peritoneum has been sutured, the inter- 
 nal oblique and conjoined tendon should be drawn down if possible 
 and sutured to Poupart's ligament, underneath the spermatic cord, 
 as in the Bdsshii operation (p. 787). In cases where the internal 
 oblicjue and conjoined tendon are very weak, the median reflected 
 flap of the external oblique aponeurosis may be included in the sutures 
 with them, and be drawn down and sutured to Poupart's ligament 
 beneath the spermatic c6rd; then the lateral reflected flap of the 
 external oblique is sutured over the cord (E. WyJlys Andrews, 1S95). 
 If the cremaster is well developed it may be employed as an additional 
 layer in suturing the canal. Another plan may be adopted where 
 the conjoined tendon is so thin that it will not hold the sutures; an 
 incision is made through the transversalis fascia along the lateral 
 border of the conjoined tendon, raising it and the anterior sheath of 
 the rectus off this muscle, whose fibres are then drawn over and sutured 
 to Poupart's ligament {Bloodgood, 1898). When, as is often the case, 
 the sac is blended with the much relaxed overlying structures, no 
 attempt should be made to separate them, but G. G. Davis's operation 
 (1905) should be employed: these blended tissues are divided trans- 
 versely, and are overlapped from above downward, much as in Mayo's 
 operation for umbilical hernia (p. 778). This gives very satisfactory 
 closure. The use of silver filigree or of a free fascial flap, as noted at 
 p. 774, may be desirable in some cases. 
 
 However the deeper structures are sutured, the skin is closed in 
 the usual way, and after-treatment is conducted as after operations 
 for indirect inguinal hernia. 
 
 Femoral Hernia. — Femoral or Crural Hernia has also been termed 
 merocele. The hernia protrudes through the femoral canal, beneath 
 Poupart's ligament, on the median side of the femoral vein. As 
 already noted, it is commoner in women than in men, especially in 
 w^omen after the menopause. In childhood it is rare. Though in most 
 cases there is a preformed sac, this may not always be a congenital 
 deformity,^ but may be a traction diverticulum probably due to the 
 
 1 According to Lockwood, a congenital sac in the femoral canal is to be attrib- 
 uted to traction by aberrant strands of the gubenernaculum testis. 
 
794 HERXIA 
 
 fact tliat some of the preperitoneal fat is forcecl into the femoral canal 
 and gradually draws the peritoneum after it. Such a sac may exist 
 for many years before a hernia forms; Murray found this condition 
 in 48 out of 200 cadavers. Most of the femoral hernice I have seen 
 have been of sudden formation, clearly indicatino; the previous 
 existence of a sac. 
 
 As the hernia develops, it carries before it preperitoneal fat (septum 
 crurale) and transversalis fascia (crural sheath). While still in the 
 femoral canal it is known as an incomplefe femoral Jiernia. Increasing 
 in size, it leaves the femoral canal, causes bulging of the criijriform 
 fascia, and curves upward over the falciform process of fascia lata, and 
 lies beneath the skin of the groin {complete femoral hernia). It seldom 
 grows very large. The only contents of the sac often is omentum, 
 but neither this nor intestine is likely to become irreducible without 
 becoming at the same instant strangulated. Strangulation probably 
 is more frequent in femoral than in any other form of hernia, and 
 gangrene occurs more rapidly, owing to the sharp margins of the 
 femoral canal. Small intestine is much more frequently present in 
 the sac than the colon, but the cecum sometimes is found; A. C. Wood 
 (190(3) has collected 100 cases in which the \ermiform appendix was 
 the only structure in the sac. 
 
 Rare Forms of Femoral Hernia. — The sac of a femoral hernia may have 
 one or more diverticula, and such cases have been described as sepa- 
 rate forms of femoral hernia: there are recognized (1) a diverticulum 
 through the cribriform fascia, or hernia of Hesselbach (1816); (2) a 
 diverticulum through the superficial fascia, or hernia of Cooper (1807); 
 (3) a properitoneal diverticulum, or hernia of Tessier (1834). A more 
 frequent, but still very rare variety, is called a pectineal hernia, or 
 hernia of Cloquet (1814); in this the sac passes from the femoral ring 
 between the pectineus muscle and its sheath, instead of anterior to 
 the latter as in the usual form; if large the sac may extend outward 
 beneath the femoral vessels. Ulrichs (1911) refers to 15 cases of this 
 variety of femoral hernia which was well studied in 1907, by Dege. 
 This hernia is to be distinguished from another rare variety, in which 
 the sac enters the sheath of the femoral vessels, and passes into the 
 thigh behind them (hernia retrovascularis). There have been recorded 
 also a few cases of femoral hernia external to the femoral vessels, between 
 the ilio-pectineal ligament and the femoral artery (hernia of Partridge, 
 1846). A hernia through an opening in Gimbernat's ligament was 
 described first by Laugier (1833) and is known by his name; it is on the 
 median side of the obliterated umbilical artery. 
 
 Diagnosis. — A femoral hernia is to be. distinguished from other forms 
 of hernia, from enlarged lymph nodes, from subcutaneous lipoma, 
 from varices of the saphenous vein, and from psoas abscess. 
 
 1. An inguinal hernia appears first above Poupart's ligament, and 
 can be retained within the abdomen, after reduction, by pressure over 
 the inguinal canal. A femoral hernia always makes its first appear- 
 ance below Poupart's ligament, and it will not be retained within the 
 
FEMORAL HERNIA 795 
 
 abdoinon if pressure is made only over the inguinal canal. If the hernia 
 is irredueihle the (hajiiiosis is more (hflicMlt; hut if an inia|,Mnary line 
 is drawn from tlie spine of the ])uhis to the anterior superior spine of 
 the ihum, it is safe to say that a liernia wliose eiiief hulk lies below 
 that line (which corresponds to Poupart's ligament) is a femoral 
 hernia (Fiij:. ~!>5I). 
 
 Fig. 799. — Right femoral hernia. Episcopal Hospital. 
 
 2. If an obturator hernia is present, the femoral canal will be empty, 
 which is never the case if a femoral hernia exists. 
 
 3. In femoral adenitis the swelling may occur over the femoral canal, 
 but it transmits no impulse on coughing; moreover, it presents signs 
 of inflammation and a primary source of infection usually can be 
 found. But as a strangulated femoral hernia may be present behind 
 inflamed lymph nodes, it is safer to operate in cases of doubt. The 
 same is true in cases of fatty or other tumors overlying the femoral canal. 
 
 4. A varicosity of the long saphenous vein may protrude over the 
 femoral canal. It transmits an impulse when the patient coughs, 
 but though, like a hernia, it disappears when the patient lies down, 
 its reduction is not attended by gurgling, nor when the patient stands 
 up will its reappearance be prevented by pressure over the femoral 
 canal. 
 
 5. A psoas abscess is secondary to tuberculosis of the spine, which 
 usually may be detected by proper examination. When the abscess 
 descends below Poupart's ligament it usually appears on the outer 
 side of the femoral vessels. Though it may transmit an impulse on 
 coughing, and may be reducible, this reduction is not attended bj^ the 
 gurgling so characteristic of hernia. 
 
 Treatment of Femoral Hernia. — The use of a truss is unsatisfactory 
 even in retaining the hernia within the abdomen, as it is impossible 
 to obliterate the femoral canal ; the most that a truss can do is to close 
 its lower (crural) opening. No cure wdthout operation need be antici- 
 pated; and in no form of hernia is a cure so necessary, owing to the 
 great frequency wath which strangulation occurs. 
 
 1. The usual operation is done b}' the femoral route. The skin 
 incision may be straight, in the long axis of the body, directly over the 
 
796 
 
 HERNIA 
 
 femoral canal, or a flap may be outlined, convex outward, so that the 
 line of skin sutures will be far removed from the genitalia (Fig. SOO). 
 The incision should commence well above Poupart's ligament, and 
 should expose also the fascia lata and cribriform fascia over the upper 
 part of Scarpa's triangle. Care should be taken not to wound the 
 long saphenous vein. When the skin and subcutaneous tissues have 
 been reflected, the sharp margin of the falciform process of the fascia 
 lata is to be located. Beneath this the femoral artery will be felt 
 pulsating, and to the median side of this is the femoral vein which is 
 in constant danger of injury. On the median side of the wound the 
 surgeon should identify the pectineus muscle and its fascia. Then 
 the sac may be opened. If the hernia is large and irreducible, which 
 is seldom the case, it may be impossible to identify these various 
 structures until the sac has been opened and its contents reduced. 
 
 Fig. 800. — Incision for femoral hernia: a a', for the inguinal method; b b', longi- 
 tudinal incision for the crural method; c c', flap incision for the crural method. 
 
 Under such circumstances the operator must cut down layer by layer 
 until the sac is opened. It is seldom possible to identify the various 
 coverings of the hernia. The omentum in an irreducible femoral hernia 
 nearly always requires to be excised in entirety. When the contents 
 of the sac have been reduced, the sac must be traced up into the femoral 
 canal under Poupart's ligament until parietal peritoneum is reached. 
 This is known by its being whiter, denser, and more fibrous than the 
 walls of the hernial sac. The opening in the parietal peritoneum is 
 then closed with a purse-string suture, and the sac is cut away, with 
 the usual precautions against overlooking hemorrhage from the 
 stump (p. 789). P>om recent observations (Ochsner) it seems probable 
 in most cases of femoral hernia, except where the femoral canal, is 
 widely dilated, that accurate suture of the parietal peritoneum is a 
 sufficient preventative of recurrence, even without any attempt to close 
 
FEMORAL HERNIA 71)7 
 
 tlio tViiioral fjiiial hy suture. Hut in most cases it is not wry (iiflicuit 
 to insert one or more sutures so as to obliterate the canal. The needle 
 (curved and round ])()inted), threaded with cliromic catj::ut, is entered 
 on the superficial surface of I'oupart's li«,Mnient, close to the femoral 
 vein, and is made to emerge in the femoral canal, catching some of the 
 fihres of the sheath of the femoral vein if possible to do this without 
 puncturing the vein. The needle is again gripped in the needle-holder, 
 and is passed trans\-crscly inward, taking a firm hold of the pectineal 
 fascia and underlying muscle, and is again grii)ped in the needle-iiolder. 
 The needle is then passed through Poupart's ligament from below 
 upward, near its inner end, and emerges finally near its original point 
 of entrance on the superficial aspect of Poupart's ligament. This 
 completes the first purse-string suture of the femoral canal (Fig. (SOI). 
 If there is room, a second similar suture may be passed nearer the lower 
 
 Fig. 801. — Crural operation for femoral hernia: closing the femoral canal. 
 
 (crural) orifice of the femoral canal. When these sutures are tied, 
 Poupart's ligament is pulled down against the pectineal fascia, and 
 the femoral canal is closed. The needle always should be introduced 
 first on the side of the canal where the femoral vein lies, as there is 
 thus less danger of injury to this important structure. The skin wound 
 is then closed in the usual \vay. 
 
 2. The inguinal route for operation in cases of femoral hernia, intro- 
 duced, in 1892, by Ruggi, does not seem to have been employed much 
 in this country, though it possesses many advantages, which I shall 
 mention after briefly describing the operation. The skin incision is the 
 same as in the operation for inguinal hernia (Fig. 800, a a'), and the 
 external oblique is divided, freely exposing the inguinal canal. The 
 lower border of the internal oblique and the conjoined tendon (with the 
 spermatic cord or round ligament) are then pulled upward and toward 
 
798 
 
 HERXIA 
 
 the median line by a retractor, drawint; the transversalis fascia tense, 
 and exposing the superficial aspect of Hesselbach's triangle — bounded 
 below by Poupart's ligament, internally by the conjoined tendon, 
 and on the outer side by the deep epigastric artery (Fig. 802) . The 
 
 Fig. 802. — Inguinal operation for right femoral hernia: the aponeurosis of the external 
 oblique has been divided, exposing the inguinal canal. The transversalis fascia has 
 been divided, exposing the gac of the hernia entering the femoral ring. 
 
 trans\'ersalis fascia is then incised on the inner side of, and parallel 
 to, the deep epigastric vessels. This at once exposes the pouch of 
 peritoneum, as it enters the upper (abdominal) orifice of the femoral 
 canal, to form the femoral hernia. It lies just to the median side of 
 the external iliac vein, in full \iew. The hernial sac is then drawn out 
 
 Fig. 803. — Inguinal operation for right femoral hernia: the sac has been removed and 
 the parietal peritoneum sutured; Poupart's ligament is now being sutured to Cooper's 
 ligament. Gimbernat's ligament in full view. 
 
 of the femoral canal, and into the inguinal wound. It is opened and 
 its contents are reduced. It is then easy to close by suture the opening 
 in the parietal peritoneum well above the neck of the sac. These 
 steps having been accomplished, the siu"geon may insert a purse-string 
 
OBrURATOR HERNIA 79U 
 
 suture iu the IVnioriil caual, precisely as in tlie erural method of 
 operation, except that the steps of this suturing are under better 
 control of the eye. i'oupart's ligament is pulled down by the sutures 
 against Cooper's ligament, firmly closing the femoral canal at its 
 abdominal opening (Fig. Hi)'^). The internal oblique and conjoined 
 tendon arc then allowed to fall back in place; Parlavecchio and 
 Dujarier suture them to Cooper's ligament, over the sj)ermatic cord. 
 If tiu> inguinal canal appears weak they may be sutured beneath the 
 cord either to Cooper's or to Poupart's ligament. The operation is 
 then concluded, as in cases of indirect inguinal hernia. 
 
 I ha\e cmployetl this inguinal method for the treatment of femoral 
 hernia for a number of years, and regard it as superior in every way 
 to the femoral route. It is simpler, easier, and I believe also safer. 
 In uncomplicated cases it enables the surgeon to excise all of the sac, 
 the whole of which is readily drawn up into the inguinal w^ound; and 
 it ensures closure of the parietal peritoneum without leaving a pouch 
 which will predispose to recurrence. In complicated cases it gi\'es 
 much freer exposure of the parts, and renders the surgeon master of 
 the situation: if there is strangulation, the constriction is much more 
 readily found and easily divided; if there is an anomalous distribution 
 of the obturator artery, it is easily discovered, and accidental hemor- 
 rhage may be promptly- controlled.; if the gut is gangrenous, and 
 intestinal resection or anastomosis is required, these may be done much 
 more rapidly and safely than by the femoral method. By the latter 
 route Gim))ernat's ligament, the usual point of constriction, cannot 
 be divided under control of the eye; it may be impossible, owing to 
 shortness of the mesentery, to draw down enough healthy bowel to 
 perform a resection, and even when the anastomosis is accomplished, 
 if one is required, it may be impossible to return the gut through the 
 narrow femoral canal. The only alternative in such cases is to divide 
 Poupart's ligament, a procedure which renders recurrence of the 
 hernia almost certain, and in a form which it is extremely difficult 
 to cure. Should there be a fecal abscess in the sac, however, it should 
 be drained through a femoral incision before the inguinal operation 
 is begun. The peritoneal cavity also should be well protected by gauze- 
 packs before the gangrenous gut is reduced. If it proves impossible 
 to draw^ the sac up into the inguinal canal, its neck should be opened 
 and its contents should receive appropriate treatment. Under these 
 circumstances the fundus of the sac may be allowed to remain in the 
 femoral canal. 
 
 Obturator Hernia. — This is very rare. Berger found it once among 
 10,000 cases of hernia. About 200 cases are on record. It is most fre- 
 quent in elderly women. It is a hernia of slow" formation. The sac 
 leaves the pelvis through the obturator foramen, and protrudes in 
 the upper inner part of Scarpa's triangle, underneath the pectineus 
 muscle, where the hernia can be more easily felt than seen. The thigh 
 should be flexed, adducted, and rotated slightly outward: then the 
 surgeon places his finger against the descending ranius of the pubis 
 
800 
 
 HERNIA 
 
 behind the addiietor h)iijiiis, and palj)utes carefully for tlie swelling 
 (Maeready). The two limbs should be e()mj)ared. Sometimes l)oth 
 sides are affected. The sac usually contains bowel, but the tube and 
 ovary have been present in a few cases. The existence of a hernia 
 seldom is recognized until strangulation occurs, and even then the 
 true cause of the symptoms may be overlooked. 
 
 Diagnosis. — The diagnosis in a case of strangulation, apart from the 
 symptoms of intestinal ol)struction, would depend on the history of 
 previous attacks of incarceration of the hernia, with relief of pain 
 coincident with the sensation of something slipping back into the 
 pelvis; the onset of the present symptoms with sudden pain in the 
 region of the obturator foramen; on the radiation of pain in the dis- 
 tribution of the obturator nerve; and on the discovery of a tender 
 swelling beneath the pectineus muscle, by the mode of examination 
 already indicated, together with palpation of the inner surface of the 
 obturator foramen througli the ^'agina or rectum. 
 
 Treatment. — Treatment consists in laparotomy and reduction of the 
 hernia, with closure of the obturator canal by suture. The mortality 
 has been about 85 per cent., largely because the condition has not been 
 recognized in time. 
 
 Fig. 804. — Left pudendal hernia, containing ovary, in a woman of eighty years. Diag 
 nosis at operation (symptoms of strangulation). Recovery. Episcopal Hospital. 
 
 Perineal, Pudendal, and Vaginal Herniae. — These are extremely 
 rare. It is probable that congenital anomalies of the pelvic peritoneum 
 (possibly preformed pouches) predispose to the development of these 
 hernise. They occur about six times as often in women as in men. 
 In the male the protrusion occurs in the perineum {perineal hernia), 
 between rectum and prostate, or rarely in the ischio-rectal fossa. It 
 may be associated with prolapse of the rectum. In the female the 
 hernia may leave the pelvis behind or in front of the broad liga- 
 ment. In the former case the protrusion may occur in the perineum, 
 in the ischio-rectal fossa, or in the posterior vaginal wall (vaginal 
 hernia). Vaginal hernia usually is associated with procidentia uteri. If 
 
ISCHIATIC Hh'RNIA SOI 
 
 tlic iKTiiia loaxc's 11k' (h'1\ is in Iroiit ol" tlic hrdud lii^aiiiciit, as is more 
 ohvu tlic case, it enters the hibiiiiii majus {yiidendal hernia, Fig. <S()4), 
 wiiere it must he (listiiij;iiislieil from (1) an iiiniiiiio-lahial lieniia, 
 which j)asses aho\e tlie hrim ol" the })el\is, through tjic inj;iiinal canal; 
 and from (2) a femoral hernia, which also leaves the abdomen ahoxe 
 the hrim of the pelvis, and which has the neck of its sac external, 
 not internal, to the descen(lin<;' raimis of the j)uhis. 
 
 Treatment. -Treatment usually is palliative, by the application of 
 a suitable pessary, T-bandage, or other ai)pliance. Strangulation is 
 rare. Operation is undertaken only wlien the hernia forms a com- 
 plication of another condition, such as prolapse of the rectum, \agina, 
 or uterus. 
 
 Ischiatic Hernia. — These are also extremely rare forms of hernia. 
 Koppl (1!)()8) has collected 23 cases. lie prefers Waldeyer's classifica- 
 tion: (1) Hernia Ischiadica Suprapyriformis. (2) Hernia Ischiadica 
 Infrapyriformis. (o) Hernia Ischiadica Spinotuberosa. The first and 
 second forms occur througli the greater sacrosciatic foramen (11 cases 
 above, and 7 below the pyriformis muscle) ; the third form (only one 
 case recorded) occurs through the lesser sacrosciatic foramen. In four 
 of the recorded cases the particular form was not described. 
 
 These hernia occur into a preformed sac, either congenital, or formed 
 by the traction of a gluteal lipoma, myxoma, or other tumor. They 
 make their external appearance along the perineal border of the 
 gluteus maximus muscle, and it is difficult to distinguish them from 
 perineal hernia. If strangulation occurs, the swelling should be 
 explored and drained from below; then the abdomen should be opened, 
 and the gut reduced. The general mortality of the reported cases is 
 34 per cent. 
 
 51 
 
CHAPTER XXII. 
 
 ABDOMINAL SURGERY IN GENERAL, AND INJURIES OE 
 THE ABDO.AIINAL VISCERA. 
 
 THE PERITONEUM. 
 
 The large serous sac known as the j^eritoneum is of immense impor- 
 tance in surgery. It forms the omentum and mesenteries, and covers 
 closely the gastro-intestinal tract, and less completely the liver, gall- 
 bladder, and pancreas, as well as the spleen, kidneys, bladder, and 
 female organs of generation. Its total area is said to exceed that of 
 the skin which covers the surface of the body. There is present 
 normally a small amount of fluid, just sufficient to lubricate the endo- 
 thelial surfaces. This fluid or any extraneous material introduced 
 into the peritoneal cavity is absorbed largely in the region of the 
 upper abdomen, especially through the peritoneum lining the under 
 surface of the diaphragm. It is believed that a constant upward 
 current exists from the peritoneal cavity through the diaphragm to 
 the mediastinal lymph nodes; and absorption of intraperitoneal exu- 
 dates occur much more rapidly by this route than through the mesen- 
 teric lymph nodes which drain the mucous surfaces of the abdominal 
 viscera. Absorption from the peritoneal cavity is hindered largely by 
 a faculty which the peritoneum possesses in common with all serous 
 membranes — that of forming adhesions. Advantage of this is taken 
 in surgery whenever any operative procedure becomes necessary on 
 organs covered with peritoneum. Isolation of an infected area is 
 favored by the insertion of gauze packs, which will within a few 
 days excite adhesions of sufficient strength to wall ofl' the general 
 peritoneal cavity. Tlie slight mechanical trauma inflicted by 
 the insertion of sutures arouses sufficient reaction in the apposed 
 serous surfaces to ensure their adhesion if contact is maintained by 
 the sutures for a week or ten days; hence such sutures always are 
 inserted in such a manner as to bring serous surfaces into contact with 
 each other. In cases of infection of the peritoneum by bacteria and 
 their toxins, the injury to the endothelial surface of the peritoneum 
 is sufficient in most cases to cause adhesion between adjacent serous 
 surfaces, and it is in this way that infectious processes are localized. 
 While this results in encapsulation of an infecting focus, it also 
 entails a certain amount of impairment of function in interference 
 W'ith peristalsis. 
 
 Peritonitis. — Inflammation of the peritoneum is one of the most 
 frequent abdominal conditions met with in surgery. It is caused by 
 
PERITONITIS S()3 
 
 l);K'tori;iI infection. Tlie existence of "idiopathic" i)eritonitis is no 
 longer rccounized. K\-en if we cannot find the ])ortal of infection, 
 we can at least identify the inicro(")r<^anisnis which are the nltiinate 
 cause of the j)eritonitis; and it may be accepted as an axiomatic truth 
 that in practice no peritonitis exists unless it has been caused by 
 bacteria. K\))eriinentally an asepti(; peritonitis may be produced l)y 
 the intraperitoneal injection of irritatin<f but sterile chemicals; and 
 theoretically when any incision into the peritoneal ca\ity is repaired 
 the process of union which occurs is a form of peritonitis; but what 
 is understood by the term peritonitis standing alone, is a bacterial 
 in fret ion of thr prrifonciim. 
 
 Causes. — The bacteria and their toxins gain access to the jxTi- 
 toneum in various ways. (1) In the immense majority of eases 
 they come from the gastro-intestinal tract, which always is swarming 
 with bacteria; these escape from the intestinal tract as the result of 
 lesions which will be studied in the next chapter (appendicitis, intes- 
 tinal obstruction, cholecystitis, etc.). (2) In a large proportion of 
 cases in the female the infection comes from the internal genitalia. 
 (3) In a few cases infection is carried from without by injury; but in 
 these cases the infection which results from injury of the intraperi- 
 toneal organs is much more serious than that which is carried into the 
 wound by the vulnerating body. (4) In a small proportion of cases 
 the infection is believed to be hematogenous in origin. (5) In excep- 
 tional cases peritonitis develops from extension of inflammation from 
 some focus in kidney, bladder, diaphragm, abdominal wall, or other 
 neighboring structure. 
 
 The microbes most frequently encountered are the staphylococcus, 
 streptococcus, and colon bacillus, in enterogenous infections; the 
 gonococcus and streptococcus in genital infections; and the tubercle 
 bacillus or the pneumococcus in those apparently of hematogenous 
 origin. 
 
 Pathology. — As a rule, peritonitis begins as a more or less localized 
 process in the immediate neighborhood of the atrium of infection 
 whether this be the vermiform appendix, the gall-bladder, the Fallopian 
 tube, an ulcer in the gastro-intestinal tract, or any other lesion (Plate 
 VII, fig. 1). Peritonitis always is either increasing or decreasing; it 
 does not remain stationary. It is not a state but a process; it runs 
 a more or less definite course, sometimes of infinite complexity, owing 
 t6 changes, which will be studied in detail later. The disease pro- 
 gresses either to recovery or to death of the patient, as surely as does 
 inflammation of any other structure in the body, as pointed out in 
 Chapter I. Its course is so very markedly influenced by treatment 
 that this important fact sometimes is overlooked. 
 
 The omentum plays a much more conspicuous part in the process 
 of peritonitis than is generally recognized. This structure may be 
 regarded as an aggregation of phagocytes enmeshed in fat. The 
 endothelial cells which line its surface are highly phagocytic. The 
 omentum is the chief source of the reactive processes which are aroused 
 
804 ABDOMINAL SURGERY IN GENERAL 
 
 by peritoneal infection. By chemotactic attraction it is drawn to the 
 point of attack, and it envelops the infecting lesion in the endeavor 
 to localize it. Other adjacent structures also become adherent to each 
 other. When the peritonitis has been thus localized the further 
 progress of the inflaniniation is the same as that which occurs else- 
 where when the protective forces are in the ascendant: the phagocytes 
 accomplish their task, the bacteria are killed and their toxins neutral- 
 ized, and the patient recovers from his attack of peritonitis. Bid 
 the omentum remains adherent to the diseased area; and more or less 
 extensive intestinal adhesions persist. There may or may not be the 
 formation of an abscess beneath the omentum, or in the midst of intes- 
 tinal adhesions (Plate VII, fig. 3). If one is formed, it will run the 
 same pathological course as an abscess in other situations; it will tend 
 to point and to rupture at the site of least resistance, and this may be 
 into the surrounding peritoneal cavity, into the bowel, bladder, etc., 
 or rarely through the overlj'ing abdominal wall. The frequency and 
 great danger of intraperitoneal rupture makes it incumbent on the 
 surgeon to recognize and to drain such an abscess as soon as possible. 
 
 If intraperitoneal rupture of such an abscess is followed by a slight 
 attack of peritonitis only, which at once becomes localized in the form 
 of a second abscess; and if this abscess ruptures in turn and a third 
 abscess is formed, and so on until multiple abscesses exist, then the 
 condition corresponds to the progressive fibrino-punilent peritonitis of 
 Mikulicz (1889). A large part of the peritoneal cavity may be invaded 
 in this way, the intestines, omentum, and neighboring structures 
 being matted together in an inextricable mass of adhesions among 
 which are found numerous minute abscesses. This occurrence is rare. 
 
 If the primary infection is very severe the bacterial toxins may be 
 diffused within the peritoneal cavity before the omentum has an 
 opportunity to encapsulate the source of infection. Then you will 
 find on opening the abdomen that the omentum appears to have 
 dissolved itself into an exudate which is rich in anti-bodies and which 
 on culture you will often find sterile. The bacteria are enclosed in 
 phagoc}i:es, or are adherent to the omentum, or to the parietal or vis- 
 ceral peritoneum. The omentum, as I said, seems to be dissolving in 
 fluid; it feels extremely slimy, and you cannot tell where omentum 
 ceases and where the fluid begins; if you hold the omentum up it will 
 almost drip this fluid from its meshes. There are no adhesions any- 
 where. Everything is covered by serous slime. This is the stage of the 
 process which is recognized as spreading or diffuse peritonitis (Plate 
 VII, fig. 2). The bowels are not much altered: those nearest the seat 
 of disease may be red, their lustre may be slightly diminished, and 
 they may even feel a little sticky; but that is all. The battle between 
 the attacking and repelling forces is as yet undecided; the process is 
 very acute, and it changes with alarming rapidity. This change 
 may be either for the worse or the better. If the latter, then the 
 anti-bodies gradually overcome the toxins, evidences of systemic 
 poisoning (toxemia) subside; the peritoneal exudate becomes thicker 
 
PLATE VII 
 
 Peritonitis. 
 
 1. Acute local peritonitis, from appendicitis. 2. Acute diffuse peritonitis. 3. Single, primary abscess. 
 4. General peritonitis. 5. Multiple, residual abscesses. (After de Quervain.) 
 
PERITONITIS 805 
 
 and more sticky; lymph cox its the inllaiiR-(J intt'stiiics wliere their 
 endotiieliiil coverinji; has hccn destroyed; frank pus begins to colk'ct 
 in deiKMuK'nt situations and pockets of the jx'ritoneal ca\ity; and as 
 th(> rej)arati\e process continues tlie infectious material is iocahzed 
 in one or many regions, wliieli are shut off from tlic rest of tlie peri- 
 toneal cavity l)y adliesions between the coils of intestine, the omentum, 
 the parietal peritoneum, and neighboring structures, such as bladder, 
 uterus, stomach, gall-bladder, diaj)hragm, etc. The result of such an 
 attack of peritonitis is the formation of nniltiple residual abscesses. 
 INIany surgeons confuse this condition, which is frequent, with that 
 described by Mikulicz as progressive fibrino-i)urulent peritonitis. The 
 pathogenesis of the latter form of ])eritonitis, which is rare, has })een 
 described abo\e; T beliexce the idea tliat it is of fre(iuent occurrence 
 rests on faults of observation. Purulent exudates collect, and residual 
 abscesses form chiefly in the dependent portions of the peritoneal 
 cavity, especially the pelvis, the iliac fossa, tJie lum})ar gutters, or in 
 the subphrenic regions (Plate VII, fig. 5). 
 
 If the resistive powers of the patient prove unequal to the task of 
 localizing an attack of peritonitis after it has reached the diffuse stage, 
 the infection continues to spread, until what may be called general 
 peritonitis is present (Plate VII, fig. 4). From this patients seldom 
 reco^'er. They die of toxemia or septicemia before the invading forces 
 have been overcome. And if the virulence of the infecting organisms 
 is very high, or if the patient's resistance is very much below par, the 
 peritoneal infection may spread with alarming rapidity from the very 
 first. In such cases little or no exudate is formed, but, on the con- 
 trary, the bacterial poisons are c^uickly absorbed, and the patient dies 
 with a dry peritoneum, without adhesions, without exudate, but 
 with the intestines red, friable, and on the verge of disintegration. 
 This usually is described as septic peritonitis, though the term of 
 A. O. J. Kelly (1896), toxic peritonitis, is preferable. When there is a 
 tendency for minute hemorrhages to occur, either in the subserous 
 tissues, or free into the peritoneal cavity, rendering the scanty exudate 
 blood-tinged, the condition is sometimes called hemorrhagic peritonitis. 
 
 Clinical Course and Diagnosis. — The symptoms of oncoming peri- 
 tonitis are so inextricably bound up with those of the condition to 
 which it is secondary, such as appendicitis, or intestinal perforation, 
 that it is difficult to distinguish between the two, especially as peri- 
 tonitis is rightly regarded not as a distinct disease, but as itself a com- 
 plication of the underlying disease. However, it is convenient to 
 describe the clinical picture which a patient with peritonitis presents 
 to the observer, and then to study more in detail the physical signs 
 on which a diagnosis of peritonitis is based. 
 
 Acute Local Peritonitis. — The initial more or less diffuse and colicky 
 pain of the primary lesion (in the appendix. Fallopian tube, gall- 
 bladder, etc.) is succeeded within a few hours by a pain which is burn- 
 ing, intense, and local. This is increased by movement, by pressure, 
 by coughing, or deep breathing. The affected area of the abdomen 
 
806 ABDOMINAL SURGERY IN GENERAL 
 
 becomes extremely tender, the muscles overlyinj? it are rigid, peri- 
 stalsis is arrested in the immediate vicinity of the lesion, and there is 
 local tympany due to paresis and distention of the bowel most affected 
 by the peritonitis. These factors account for the persistent consti- 
 pation, and the nausea and vomiting. There is moderate elevation of 
 temperature, leukocytosis, and a raj)id, hard, wiry pulse. 
 
 Acute Diffuse Peritonitis. — This usually is a sequal to the local 
 form, but in cases of gastric or intestinal perforation may exist from 
 the very first. All the symptoms are aggravated, and at the onset 
 there often is marked shock. The pain is almost unendurable, con- 
 stant, burning, or boring, and spreads w^idely over the abdomen.^ 
 The abdomen is of board-like rigidity. throughout, and exquisitely 
 tender. The patient's respiration is entirely thoracic, and the flat 
 or even scaphoid abdomen moves not at all, even in deep inspiration. 
 The patient lies on his back or side, with knees drawn up to relax the 
 abdominal muscles. The constipation is absolute; no flatus is passed; 
 peristalsis is entirely absent; vomiting is almost continuous, the patient 
 regurgitating with little eft'ort, every few minutes, small amounts of 
 offensive prune-colored liquid. The symptoms of this stage pass 
 almost imperceptibly into those of general peritonitis. The evidences 
 of systemic poisoning become pronounced : there is more fever, greater 
 leukocytosis, rapid, shallow respiration; the eye is bright, the expres- 
 sion anxious, and the skin from being rough and dry becomes covered 
 with a clammy moisture. The pulse grows very rapid, running, weak, 
 and almost uncountable. The abdomen begins to become distended, 
 rigidity lessens and then disappears; extreme distention finally 
 develops. In the last stages tenderness and leukocytosis may be 
 absent. Death is preceded by delirium, great restlessness, cyanosis, 
 air hunger, sweating, subsultus tendinum, carphologia, and finally 
 exhaustion. In rare cases of very severe infection, from the first, 
 and not infrequently before death, the abdomen is soft, and there is 
 diarrhea ("septic diarrhea"). 
 
 The history of the case is of great value in diagnosing the primary 
 lesion, but in peritonitis, as in most other acute lesions, much more 
 reliance can be placed on physical signs than on the clinical history or 
 the symptoms. It is well, therefore, to consider in more detail some 
 of the physical signs which were enumerated above. 
 
 Rigidity of the Abdominal IFa//. — This is due to reflex (involuntary) 
 muscular contraction, brought about by stimulation of the spinal 
 segments, whence arise both the nerves supplying the diseased abdomi- 
 nal viscera (sympathetic fibres) and those which supply the over- 
 lying muscles of the abdominal wall. So long as the peritonitis is 
 localized, the rigidity wdll remain local; spread of rigidity is an indica- 
 tion that the peritonitis is spreading in a similar manner. In some 
 
 1 Peritonitis limited to the area occupied by the small intestine, and confined 
 beneath the omentum, may run its course without any of the usual symptoms, so 
 long as parietal peritoneum is nowhere affected; it is only the parietal peritoneum 
 which has pain sense, according to Lennander, while that covering the viscera is 
 insensitive. 
 
PERITUMTIS 807 
 
 cases the stimulus seems to alVect the sensory as well as the motor 
 iierxc Hlaments of the ahdominal wall, and hyperesthesia ol" the skin 
 oxerlyinj; the diseased \iseus is present. ( Onversely, inexpert j)alpa- 
 tioii of the ahdominal wall with a eold hand, or with fin^'ers lacking 
 in skill and jjentleness, will stimulate these sensory cutaneous filaments, 
 and will cause contraction of the abdominal nmscles, and thus may 
 make the careless examiner think that rij^idity flue to i)eritonitis is 
 present, when he has himself caused this rigidity by his inexpert 
 examination. The true reflex rigidity of the abdominal muscles can 
 be recognized only by experience, and many physicians never learn 
 to recognize it, owing to inditierence and lack of practice. It is the 
 tadus cruditufi, the experienced touch, that counts, and the only way to 
 gain this experience is to palpate with attention and care the abdomens 
 of hundreds of patients with and without peritonitis. 
 
 Palpation for muscular rigidity should be made with the finger 
 ti])s, but with the utmost gentleness. Place the ti])s of all four fingers 
 of both hands very lightly on the surface of the abdomen at some 
 point far rernoved from the region suspected of disease and palpate 
 the normal abdominal wall first. Do this gently and circumsi)ectly 
 in every case, and you will gain your patient's confidence, and further 
 palpation will be easier. Having placed the fingers barely in contact 
 with the abdomen, arrange them so that alternate pressure wath each 
 hand will be in a direction parallel to the course of the fibres of the 
 muscle you are about to palpate. Then, without at any time raising 
 your fingers from the surface of the abdomen, and with extreme 
 gentleness, bear down for a fraction of a second first with one hand 
 and then witli the other. Repeat this manipulation a number of 
 times before passing to another region of the abdomen, and accom- 
 plish this transfer of your hands without raising them from the abdomi- 
 nal wall, so as to spare the patient the shock of a new contact. Having 
 reached another region, repeat your manipulations here, and so on 
 until the entire abdomen has been covered. This should include the 
 rectus muscle of each side both above and below the umbilicus, and 
 the oblique muscles not only in the iliac and hypogastric regions, 
 but in the flanks and in the loins as well. In this way you will very 
 quickly learn the difterent sensation conveyed to the palpating finger 
 by a rigid or a normally relaxed muscle. Do not be in a hurry, and 
 be more gentle than you think anyone else can be. This is not at 
 all the same kind of palpation that is desirable when one is seeking 
 to discover a mass wdthin the abdomen. It is this latter form of 
 palpation that most physicians attempt when they seek for rigidity, 
 with the result that they usually fail to recognize its presence. Here 
 the hand is laid flat on the belly, and by gentle and rocking pressure 
 alternately with the heel of the hand and the pulps of the fully extended 
 fingers, the examiner seeks to depress the abdominal wall until the 
 underlying structures can be palpated. 
 
 If rigidity is present, it is a clear indication that some degree of 
 peritonitis exists. Slight rigidity usually indicates a mild grade of 
 
808 ABDOMIXAL SURGERY IX GENERAL 
 
 peritonitis so long as the abdomen is not distended; and marked 
 rigidity indicates peritonitis of much more serious import. So, too, 
 the extent of the rigidity on the surface of the abdomen is a fair indi- 
 cation of the area of peritoneum involved. But if the patient is 
 excessively fat, or if the muscles are very much atrophied, no rigidity 
 may be palpable. 
 
 Tenderness on palpation is of almost equal importance with rigidity. 
 Cutaneous hyperesthesia, which was referred to above, is described 
 as superficial tenderness; what is to be studied now is known as deep 
 tenderness. When this is exquisite it usually signifies pus under ten- 
 sion, whether the pus is localized as an abscess or free in the belly as 
 in diffuse peritonitis. Rigidity scarcely ever is present without 
 tenderness, though the latter may not be elicited by very gentle 
 palpation in the case of a very muscular or extremely rigid abdominal 
 wall. But tenderness frequently persists after rigidity has given 
 way, as in time it usually does, to abdominal distention. This per- 
 sistence of tenderness is a very important sign, often indicating that 
 gangrene has occurred in the organ diseased. Palpation through the 
 rectum often is of great value, in discovering tenderness in the recto- 
 vesical pouch. 
 
 Percussion of the abdominal wall should succeed palpation. It 
 should be done with the utmost gentleness, and not over any area 
 which is very tender. It is possible by percussion, much more safely 
 than by palpation, to determine the presence of an abscess, or of an 
 inflammatory mass due to adherent omentum. These will give a 
 dull note on percussion, and will be surrounded by areas of tympany. 
 The existence of an effusion which is settling in the pelvis or the loins 
 may also be ascertained by percussion. 
 
 Finally, auscultation should not be neglected. In cases of diffuse 
 peritonitis the abdomen is quiet; no peristaltic sounds are heard 
 unless at a great distance from the focus of infection. 
 
 Distention of the abdomen is a late sign of peritonitis, and of bad 
 prognostic import. A diagnosis which is delayed until the abdomen 
 is distended is of little use. The onset of distention occurs pari 
 passu with the disappearance of abdominal rigidity. The distended 
 abdomen may be tense from tympanites, but it never is rigid. The 
 distention is the result of two factors: the first is paresis of the intes- 
 tinal nerves and of those supplying the abdominal wall, as a result 
 of poisoning by the absorption of toxins; this relaxes the muscular 
 tunic of the intestines and makes the belly wall soft. The second 
 factor causing distention is the occurrence of fermentative and putre- 
 factive changes within th^ intestines, producing tympanites. The 
 constipation which has already been noted, and the distention of the 
 abdomen which is here discussed, are the consequence and not the 
 cause of the patient's illness. He is not ill because his abdomen is 
 distended, but his abdomen is distended because he is ill. 
 
 Differential Diagnosis. — Peritonitis must be distinguished from the 
 colic of acute gastro-enteritis, from pleurisy and pneumonia, and from 
 
PERITONITIS 809 
 
 intestinal obstrnction. Other conditions with which it is sometimes 
 confounded will be discussed in connection with the several lesions 
 which may cause peritonitis. 
 
 Acute (lajitro-rntcritis.— In mild cases this is attended by sudden, 
 sharp, stabbinjj pain, which varies in intensity from time to time — 
 infcstinal colic. The pain is relieved by pressure on the abdomen. 
 There is no tenderness, no rigidity, no change in pulse or tempera- 
 ture, and no leukocytosis. Vomiting is unusual, but if it occurs it is 
 not repeated when the stomach has been emptied. In severer cases 
 there is vomiting, and general jjbdominal pain and tenderness. There 
 may be fever, with increase in the pulse rate, but there is no rigidity 
 of the belly wall; and there is diarrhea, which is rare in peritonitis. 
 In cases where doubt remains after a thorough examination, visit the 
 patient again after an interval of three or four hours, and keep him 
 in constant surveillance until the nature of the disease is manifest. 
 
 Pleurisy and pneumonia often are attended by pain referred to the 
 abdomen, and in children this may be the only complaint. There is 
 no nausea or vomiting; only slight rigidity of the upper abdomen, 
 and only superficial tenderness (cutaneous hyperesthesia) are present. 
 There is no deep tentlerness. If the chest were examined in all cases 
 of acute abdominal disease, whether the presence of pulmonary 
 complications be suspected or not, the surgeon would be saved many 
 an error and the patient an unnecessary operation. Even if the pul- 
 monary lesion is so deep-seated as to give no distinct physical signs, a 
 diagnosis of peritonitis usually may be excluded by the absence of 
 physical signs in the abdomen, and by the presence of symptoms, such 
 as rapid respiration, dyspnea, slight cyanosis, etc., which are charac- 
 teristic of thoracic disease. 
 
 Intestinal Obstruction frequently is complicated by peritonitis in 
 its later stages, just as peritonitis may be followed at any time by 
 intestinal obstruction. A differential diagnosis often is impossible 
 when either condition has existed for some days, because then both 
 conditions may be present. But at the outset the two affections pre- 
 sent very different symptoms and physical signs. In intestinal 
 obstruction, attentive study of the patient's history usually will 
 reveal a cause for the obstruction in some previous attack of peri- 
 tonitis. The attack of intestinal obstruction begins with colick}^ pains, 
 and these are more or less relieved by pressure on the abdomen. 
 The pain is intermittent, and between the 'paroxysms the patient may 
 feel quite comfortable and may appear very well. In peritonitis the 
 patient is decidedly ill from the very commencement of the attack, 
 and there are no remissions. In obstruction the intervals between 
 the pains rapidly shorten, but the pain does not for a long time become 
 constant; in peritonitis it is constant from the beginning. In obstruc- 
 tion there is absolute constipation, as in peritonitis, and no flatus is 
 passed by rectum; vomiting occurs early, is persistent, and soon 
 becomes of the projectile type (p. 885), with rather long intervals 
 between the attacks of vomiting. In peritonitis, on the contrary. 
 
810 ABDOMINAL SURGERY IN GENERAL 
 
 the patient vomits oftener, the \'()iiiitus is small in quantity each 
 time; and the vomiting is not projectile hut regurgitant in type (p. 
 806). In obstruction, as in i)eritonitis, the contents of the upper 
 bowel are vomited after the stomach has l)een emi)tied; but in obstruc- 
 tion the rejected matters finally become fecal, wliich never is the case 
 in peritonitis. In obstruction there is no rigidity of the abdominal 
 wall, and distention occurs early — often within a few hours. Rigidity 
 is the most \'aluable early sign of peritonitis, but distention seldom 
 occurs until after the lapse of eleven or twelve hours. The disten- 
 tion of obstruction may at first be localized to the area immediately 
 above the obstruction. Auscultation in obstruction detects extremely 
 active and disordered peristalsis; sometimes peristaltic waves can be 
 clearly seen through the distended belly wall. In peritonitis the 
 abdomen is silent. In obstruction the temperature is not elevated, 
 while in peritonitis it almost always is abo^'e normal. Leukocytosis 
 is rare in obstruction, unless strangulation has occurred; but in peri- 
 tonitis it is the rule. In both affections a steady increase in the pulse 
 rate occurs, and is a most valuable sign. 
 
 Treatment. — This is not the place to discuss the prcAcntion of peri- 
 tonitis; but that it may be prevented often by prompt operation 
 will be pointed out time and again in the following pages. What 
 concerns us here is how to treat the patient after peritonitis has devel- 
 oped; and I here exclude from consideration pelvic peritonitis in 
 connection with gynecological affections. 
 
 1. In the early stages, before the peritoneal inflammation has become 
 diffuse, surgeons are in perfect accord in recommending immediate 
 operation, to remove the source of infection, and thus })revent the 
 development of diffuse peritonitis. This is a much surer and far 
 safer course to pursue than to trust to the unaided powers of nature 
 to isolate and overcome the infection. If the source of infection is the 
 appendix, it can be entirely removed; if it is a perforation of the 
 intestine, it can be sutured, and the further discharge of infectious 
 material prevented; if there is a lesion which cannot be treated in 
 either of these ways (as in acute pancreatitis) the surgeon can at least 
 isolate the source of infection by gauze packs, providing drainage, and 
 thus preventing further intra-abdominal contamination. The details 
 of operation, which should be completed quickly, will be described in 
 connection with the various lesions which cause peritonitis. 
 
 2, When the peritonitis is in the diffuse stage surgeons are divided 
 into two camps. There are those who think, with Ochsner, that it is 
 safer to undertake no operation in cases of spreading peritonitis, but 
 to trust to such measures as are detailed below to aid nature in isolat- 
 ing the infection, and to wait until a residual abscess has been formed 
 before instituting drainage. Neither Ochsner nor anyone else, how- 
 ever, ever claimed that the patient could be cured without any opera- 
 tion; the only question is whether the operation shall be immediate 
 or postponed. Then there are other surgeons who believe, so long as 
 the evidences of toxemia are not very marked, and so Jong as the 
 
I'ElilTONITlS 811 
 
 degree of (ilxloiiiiiidl rifiidUji is (jreaier fluin Us (listenthnt, so loiij;-, in 
 short, as it is cvidnit that th(> patient is still reacting to tin- inlVction, 
 that throufihout this period it will l)e more to the patient's ultimate 
 advantage to institute drainage as soon as possible, and at the same 
 time to treat the foeus of infection by excision, suture, or tamponade, 
 ])rovided this secondarN' part of the operation can be carried through 
 without unduly prolonging the procedure or entailing too great 
 shock. My own belief and my practice, founded on a not very limited 
 experience with all forms of i)eritonitis, is that operation under these 
 circumstances is not only justifiable l)ut imperative. Ochsner and 
 others limit the time within which inun(>diatc ()i)eration is to be done 
 to the first thirty-six hours from the beginning of the illness. Xo 
 doubt this is a convenient rule of thumb, but one patient will reach 
 at the end of twelve hours a stage of peritonitis which will not be 
 reached by another for two or three days. So that I think it is safer 
 to decide the question in favor of or against immediate oi)eration n()t 
 on the mere lapse of time, but, as I have done above, on the jxiUcnfs 
 physiccd condiiiou. Especially valuable, I believe, is the persistence 
 of' rigid it}/ or the onset of distention. Statistics might be quoted to 
 support the views of surgeons on both sides of this question; but the 
 fallacy of trusting to such figures is obvious. Only those who open 
 the abdomen in all these cases know the state of affairs inside; those 
 who do no operation give statistics founded on impressions, not on 
 visual inspection of the peritoneum, and they are quite as likely to 
 reckon as non-operative survivals, patients whose peritonitis never 
 became widespread, as the really serious cases. 
 
 .3. When diffuse peritonitis has so far advanced that rigidity has 
 disappeared, and marked distention is present, the patient being ^'ery 
 toxic and perhaps delirious, and constantly regurgitating the upper 
 intestinal contents, almost all surgeons are in agreement with Ochsner 
 that operation is more apt to hasten death than to gi^'e the patient 
 a chance of recovery. In these cases, howTver, a well defined course 
 of treatment musi be pursued, and occasionally even a seemingly 
 moribund patient wull improve, one or more abscesses will form, and 
 if these are drained at a propitious time recovery may yet ensue. 
 This treatment, about to be described, is known as the Ochsner treat- 
 ment of peritonitis, because so warmly espoused by this surgeon ever 
 since 1900. It should be adopted in every case of peritonitis so soon 
 as the diagnosis is made, whether or not operation is to be undertaken. 
 If operation is to be done, this treatment will be of short duration, 
 but it will aid materially in securing a good result; and the sanie 
 treatment always is continued after operation until the peritonitis 
 subsides. The' most important features of this non-operative or 
 preparatory treatment are: (1) abstinence from everything hy mouth 
 (hence it sometimes is called "starvation treatment"); (2) instillation 
 of fluids by the rectum; and (3) the head high position. 
 
 The patient is placed in bed either in Fowler's position (1900), 
 hing flat on the back, and with the head of the bed raised twelve 
 
812 
 
 ABDOMINAL SURGERY IN GENERAL 
 
 to fifteen inches from the floor; or else in the so-callerl exa,2;gerated 
 Fowler position, that is, in a semi-sitting posture in the bed (Fig. 805). 
 This aids the gravitation of fluids to the pelvis and keeps them away 
 from the subphrenic region, whence absorption is so rapid, thus dimin- 
 ishing toxemia; and it lessens the chances of ])ulmonary complications. 
 The patient is very apt to slide down in the bed unless supported. 
 A special chair-like bed frame is the best support, but in emergencies 
 a sand-bag may be passed beneath the mattress below the buttocks, 
 or the patient may sit in a sling formed by tying the ends of a sheet 
 to the two u])per posts of the bed. 
 
 Fig. !S05. — Exaggerated Fowler position. One week after suture of a duodenal per- 
 foration . Note slight elevation of reservoir for enteroclysis solution. Episcopal Hospital. 
 
 Nothing ivhatever is given by mouth, not food, not water, not ice; 
 nothing is permitted. Anything taken into the stomach rouses peris- 
 talsis, and this spreads infection more widely in the peritoneum. 
 Moreover, it increases nausea and provokes vomiting. The only thing 
 ever to be introduced into the stomach is a stomach tube, wiiich 
 should be used every six hours or less often, to relieve the stomach of 
 regurgitated intestinal contents. A patient who has once experienced 
 the relief which lavage of the stomach affords under these circum- 
 stances is only too anxious to have the procedure repeated as soon as 
 he feels his stomach refilling. 
 
 To replace the fluids lost by intraperitoneal effusion, the patient is 
 given saline solution or tap water by the rectum, as already described 
 in Chapter V. This does not excite peristalsis, is quickly absorbed, 
 allays thirst, restores blood-pressure, dilutes circulating toxins, and 
 after operation seems to promote drainage from the wound. 
 
 No drugs are required as a rule. Stimulants, such as camphorated 
 oil, atropin, digitalis, or strychnin, seldom are indicated and do not 
 seem to have much effect. Mor])hin very rarely is required; the pain 
 soon ceases if nothing is taken by mouth and if nausea is controlled 
 by lavage. Unless there is pain, sleep is not much interfered with. 
 But I do not believe that morphin does any harm, and there is no reason 
 why it should not be administered if it promotes the patient's comfort. 
 
 This treatment shoiild he continued mitil the yeritonitis subsides. 
 This period seldom is longer than three days, but it may be a week. 
 
RESIDUAL PERITONEAL ABSCESSES 813 
 
 The more ahsoliito the treatiiieiit from tlie first, tlie sooner will its 
 efl'eet become manilest. I nder tliis form of treatment many patients 
 who wonld (He nnder any other form of treatment, or after operation, 
 will survive the peritonitis, and as the abdomen gradually softens, 
 the surgeon will find evidences of one or more collections of pus. Very 
 rarely a j)atient will recover from what ai)i)ears to ha\'e been a diffuse 
 septic peritonitis without elfusion; when the abdomen is ojx'ned later 
 to remove the cause of the disease, few adhesions and no pus may be 
 foimd. I have seen only two such cases. Other ])atients will die in 
 spite of this treatment; but it is not too much to say that the Ochsner 
 treatment is the only form of treatment which gives these bad cases 
 of peritonitis even a fighting chance. 
 
 After the peritonitis subsides the patient is still far from convalescent. 
 As the abdomen becomes softer auscultation will detect commencing 
 peristalsis, and it will be painless; flatus will be passed, and the bowels 
 may mo^•e s|)ontaneously or by simple enema. At this time small 
 amounts of liquid food may be allowed by mouth; but if this 
 is attempted too soon it will cause vomiting, rouse active peristalsis, 
 break up newly formed adhesions, rupture an abscess which is just 
 localizing, and perhaps cause intestinal obstruction. The patient 
 must be very carefully nursed, and progress must be sure rather than 
 rapid. When the abdomen has become entirely soft in parts removed 
 from the seat of disease, when the bowels are acting normally, and 
 the patient is a])proaching convalescence, then it is time to drain the 
 abscesses which have formed. If these are neglected, and intraperi- 
 toneal rupture occurs, the patient seldom survives even immediate 
 drainage. 
 
 Residual Peritoneal Abscesses. — So long as an intraperitoneal 
 abscess is present, the patient is in constant danger. No delay should 
 be permitted in instituting drainage when once it is ascertained that 
 the patient can withstand the intervention. The abscess should be 
 incised and drained, if possible without opening the uninvolved 
 peritoneal cavity; nothing else should be attempted. Do not make 
 any search for the cause of the peritonitis, but be content to secure 
 drainage. Make sure, however, that you find all the abscesses. Plate 
 VII, fig. 5, shows the most frequent sites in which residual abscesses 
 form. In most cases a secondary and more formal operation is indicated 
 some weeks or months later, to complete the cure by removal of the 
 diseased organ (appendix, gall-bladder), closure of a fecal fistula, etc. 
 
 Pelvic abscess sometimes may be drained by puncture through the 
 rectum, or through the vagina. Unless the anterior rectal wall bulges 
 and fluctuation is unmistakable it is safer usually to make a supra- 
 pubic incision. This always should be preferred when there is also 
 an iliac abscess; and always after opening an iliac abscess the surgeon 
 should make sure that a separate pelvic abscess is not overlooked. 
 A Ivmbar abscess is drained by an incision in the flank or loin. 
 
 Subphrenic abscess is of great importance, because, though less 
 frequent, it is so often overlooked. It may occur either (1) to the right 
 
814 ABDOMINAL SURGERY IN GENERAL 
 
 or (2) to the left of the falciform ligament of the liver; or (3) behind 
 the right coronary ligament; or (4) in the lesser peritoneal cavity. 
 Abscesses on the extraperitoneal surfaces are rare, and usually are 
 secondary to hepatic abscess, in connection with which they are dis- 
 cussed (p. 9o()). Of the four sites of subphrenic abscess mentioned 
 above, that most frequently the seat of suppuration is the space 
 behind the right coronary ligament and extending around its free 
 margin to the subhepatic space. Most abscesses in this situation are 
 secondary to appendicitis; the abscess tends to point through the lower 
 intercostal spaces, except when intraperitoneal or intrapleural rupture 
 occurs. Most of the abscesses in association with the left lobe of the 
 liver in front of the left coronary ligament are due to gastric or duodenal 
 lesions; those in the lesser peritoneal cavity may follow gastric or pan- 
 creatic lesions; while those far to the left are rare and generally sec- 
 ondary to splenic affections or are the result of diffuse peritonitis. 
 The diagnosis of subphrenic abscess is based: (1) On the history of the 
 illness, indicating a possible cause for the formation of an abscess in 
 the subphrenic region; perforated gastric or duodenal ulcers cause 
 almost one-third of these cases, appendicitis over one-sixth, hepatic 
 affections about one-sixth, and the remaining one-third are due to 
 miscellaneous affections (Barnard, 1908). (2) On abdominal signs and 
 symptoms of an abscess — dulness, tenderness, mass, possibly rigidity. 
 (3) On thoracic signs and symptoms, especially slight pleural frictions 
 or effusion, or upward displacement of the lung with increasefl dulness 
 over the liver. (4) On general signs and symptoms of suppuration — 
 fever, leukocytosis, chills and sweats, and especially progressive 
 emaciation. The treatment of subphrenic abscess involves drainage 
 by operation; nearly every patient not operated on dies. In most 
 cases of right-sided abscess the operation is by thoracotomy', as in 
 operations for abscess of the liver (p. 937). Rarely an abdominal 
 incision is proper. The general mortality is about 37 per cent. 
 
 Peritoneal Adhesions. — This condition, which has been referred 
 to (p. 802), often is described as chronic peritonitis; it is rather the 
 result of a former peritonitis. There is no inflammatory process. 
 The adhesions which developed during the existence of active inflam- 
 mation remain, and by their interference with peristalsis cause symp- 
 toms of which pain and obstipation are the most constant. The drag 
 of adherent structures on the parietal peritoneum, the mesenteries 
 or the female genitalia may render life miserable, and the patient may 
 become an invalid. Purgation is apt to rouse such acti\'e peristalsis 
 as to increase pain, and sometimes causes intestinal obstruction; 
 and the usual symptoms of coprostasis are an annoyance unless the 
 bowels are opened normally. 
 
 There are other cases in which peritoneal adhesions develop as the 
 result of such an attenuated infection that the origin of the affection 
 cannot be traced. Such are many cases of Lane's kink, of Jackson's 
 membrane, and other forms of peritoneal disease which have been 
 recognized only within recent }ears. These are discussed at p. 896. 
 
TUBERCULOSIS OF THE PERITONEUM M,') 
 
 The surgeon is powerless to prevent the formation of adlic.^ions in 
 cases of acute peritonitis, and, indeed, often hails them witii delij,dit 
 as aids to tlie i)atient's immediate recovery; l)Ut he is careful wlien 
 he opens tiie abdomen in other cases to avoid manipulations wiiich 
 will encourage the formation of useless and disabling adhesions. He 
 does not handle the parts not concerned in the operation; he with- 
 draws from the abdomen as little of the intestine as possible, and 
 prevents it from becoming dried while it is exposed; and he is careful 
 to cover all denuded serous surfaces by inversion with sero-serous 
 sutures or by stitching the omentum over the defect. Various attempts 
 have been made to j)revent peritoneal adhesions by the use of oily 
 substances, but without much success. In recent laboratory work, 
 however, Saxton Pope (1914) has found that a 2 per cent, solution of 
 sodium citrate in a 3 per cent, (hypertonic) sodium chloride solution 
 possesses great power in preventing peritoneal adhesions. 
 
 Treatment. — In the treatment of peritoneal adhesions, it is only by 
 experience that a surgeon can learn when to let well-enough alone. 
 If the adhesions are broken up the new adhesions that form may be 
 still more disabling, in spite of patient suturing and omental grafting. 
 Unless the adhesions produce symptoms it is better, as a rule, not to 
 interfere with them. Of course, if intestinal obstruction occurs, this 
 must be overcome. 
 
 Pneumococcic Peritonitis. — This occurs oftenest in ciiildren, i)ar- 
 ticularly girls under the age of six years. ]\Iost cases are secondary 
 to a pneumococcic infection of the lungs; but the primary focus may 
 be situated elsewhere, as in the middle ear or the female genitalia. 
 The infection probably is more often enterogenous than hematogenous. 
 The physical signs are those of acute diffuse peritonitis (p. 80(3), but 
 the patient's general condition is not so much affected as when the 
 peritonitis is due to the ordinary organisms, and the death rate is 
 much lower. In most cases there is a good deal of effusion, and this 
 usually becomes encysted within the course of a few days or a week. 
 It should then be opened and drained. 
 
 Tuberculosis of the Peritoneum. — The tubercle bacilli may reach 
 the peritoneum tlirough the blood-stream, from the mesenteric lymph 
 nodes, directly from the intestinal tract, or from the Fallopian tube. 
 In almost all cases there are other tuberculous lesions elsewhere in 
 the body. Tuberculosis of the lungs frequently preexists, and in a 
 large proportion of adult patients this will develop later if not already 
 present at the time the signs of peritoneal tuberculosis are noted. As 
 a complication of Pott's disease of the spine, tuberculosis of the 
 peritoneum is not very rare. 
 
 As a part of a general miliary tuberculosis (blood infection), tuber- 
 culosis of the peritoneum has no surgical interest. The cases of most 
 surgical importance are those in which a removable focus of tuber- 
 culosis. exists in the abdominal cavity. This is most often the Fallo- 
 pian iuhe in women, and the vermiform appendix in men. In children 
 tuberculosis of the mesenteric lymph nodes is more frequent. In many 
 
816 ABDOMINAL SURGERY IN GENERAL 
 
 cases a tuberculous ulcer of the small intestine is the point of peritoneal 
 infection. Here, as in the appendix, the tubercle bacilli penetrate 
 the thinned floor of the ulcer, and usually without a macroscopical 
 perforation, escape into the peritoneal cavity, which becomes widely 
 covered with miliary tubercles. These feel like minute shot or sand- 
 like particles, projecting from the serous surfaces. They are yellowish- 
 gray in color. The same course of events occurs when the infection 
 arises in the Fallopian tube, whence it may escape through the abdomi- 
 nal ostium, or by a minute perforation. It is not improbable (Baum- 
 gartner) that the lesion is not really primary in the Fallopian tube, 
 but that this has been infected from its peritoneal surface; but at all 
 events, the tuberculous process is most active here for the time being, 
 presumably because the bacilli have found a fertile soil for develop- 
 ment. Tuberculosis of a hernial sac is not very rare. Usually it is 
 secondary to some intra-abdominal focus. 
 
 The changes in the peritoneum are those characteristic of other 
 forms of peritonitis, only very much milder in degree. Usually there 
 is a moderate amount of exudate formed. This may be clear, yellow- 
 ish, greenish, turbid, or even purulent; not seldom it is bloody. When 
 the disease has lasted for many months, adhesions form, and may be 
 very extensive, causing kinks, and leading to intestinal obstruction. 
 The omentum becomes thickened and forms lumpy masses which 
 often can be felt through the abdominal wall. As the omentum and 
 mesentery both may become retracted from thickening and tuberculous 
 infiltration, these masses usually are situated in the left hypochon- 
 drium. The intestines lie mostly below and to the right, and their 
 tympanitic state adds to the distention of the abdomen. Among the 
 adherent intestinal coils small collections of puruloid matter may occur. 
 Rarely there is a large encysted collection of fluid. Caseous changes 
 in the mesenteric lymph nodes are a late occurrence. The intestinal 
 walls become very friable, and internal (entero-enteric) fistulse may 
 form; occasionally an external fecal fistula develops spontaneously. 
 In infants a tuberculous abscess may discharge through the umbili- 
 cus, as in a case under my care some years ago at the Children's 
 Hospital. 
 
 Symptoms and Diagnosis. — The disease is one of early adult life, 
 and of early childhood. Before five years of age it is not infrequent. 
 It is rare after thirty-five or forty years. Most cases occur in women 
 between eighteen and thirty years of age. 
 
 Tuberculous peritonitis may begin rather acutely, or it may be 
 chronic from the beginning. In the former case, after a few weeks of 
 malaise and gastro-intestinal derangements (colics, attacks of con- 
 stipation and diarrhea, nausea) the first thing to attract the patient's 
 attention is enlargement of the abdomen, due to serous effusion. 
 This may persist unchanged for months, but usually there are times 
 when the abdomen seems to become smaller. As time goes on, adhe- 
 sions begin to form, and if spontaneous recovery takes place (and it 
 is not unknown) the abdomen becomes softer, the bowels act normally, 
 
TUBERCULOSIS OF TlIK I'EIUTONEUM 
 
 817 
 
 the gciRTal health improves, and tlie patient eonvalesees. Or an 
 eneysted coUeetion of llnid may form, and be cured by evacuation. 
 In cases which are chronic from the beginning the i)r()dromal 
 symptoms may have existed for many montlis; there rarely is nnich 
 ell'usion; often none can be detected. Omental masses may be 
 palpabl(\ and they may change their site and their form from time 
 to time, in the course of weeks or months, from no appreciable cause. 
 Usually the subjective symptoms are slight, unless the adhesions 
 cause intestinal obstruction, or secondary infection produces hectic 
 fever. So long as the patients lie quiet in bed and are carefully nursed 
 little change in their condition may be appreciable from month to 
 month (Fig. SOO). 
 
 Fig. sou. — Tuljerculosis of the peritoneum with effusion. Episcopal Hospital. 
 
 The diagnosis of peritoneal tuberculosis will be strengthened by 
 finding any tuberculous focus elsewhere in the body. Tuberculosis 
 of the bones usually will be easily detected; but examination should 
 also be made of the lungs, testicles, prostate, seminal vesicles, and 
 kidneys, as incipient lesions in these structures often are overlooked. 
 
 Treatment. — The general hygienic treatment already recommended 
 (p. 82) for patients with tuberculosis is most important in cases of 
 tuberculous peritonitis. A fair proportion of cases, as pointed out by 
 Fenger (1901), tend toward spontaneous recovery. If improvement 
 under general hygienic treatment is progressive, no operation is indi- 
 cated. In other cases, however, effusion persists; the patient does not 
 gain ground, and may grow progressively worse. In these patients, 
 the propriety of operative interference must be considered. Operation 
 has been found, empirically, to be of most value in cases with effusion. 
 Tapping and aspiration of the fluid never have produced as good 
 results as formal incision and evacuation. Probably this is for the 
 same reasons that incision and evacuation of cold abscesses in con- 
 nection with joint tuberculosis are more successful than is aspiration; 
 the peritoneal effusion of tuberculosis is similar to a cold abscess 
 elsewhere, and it is important to prevent the occurrence of secondary 
 infection, either from the surface of the body or from within the 
 intestinal tract. The abdomen should be opened in women, as if for 
 an operation on the uterine appendages; in men, over the appendicular 
 region; as these are the most frequent sites of primary foci. When- 
 ever possible, without inflicting damage on the intestines, a tuber- 
 52 
 
818 ABDOMINAL SURGERY IN GENERAL 
 
 culous appendix in men should be removed; in women not only should 
 one or both tubes l)e removed if affected, but a diseased appendix 
 also. If adhesions are present the utmost caution should be used if 
 any attempts to separate them are made. It is very easy to tear a 
 hole in the intestine, and very difficult to repair it. Even if the intes- 
 tinal sutures can be made to hold, union very seldom occurs, and a 
 fecal fistula is the nearly inevitable result. Only if the bowel has been 
 torn should the abdomen be drained. In other cases it should be 
 closed tightly, to prevent any possibility of secondary infection from 
 the surface of the body. 
 
 In general it may be said that the immediate mortality following 
 operation is very small, if proper precautions are taken against injuring 
 the intestines. The ultimate prognosis is better when some focus such 
 as the appendix or tube has been removed. Cure occurs much oftener 
 in the ascitic than in the dry cases. If the patients are traced, nearly 
 half the number will be found to die within a few years, and there 
 will be many recurrences. But the prognosis is better with than with- 
 out operation, and even a few years of comparative freedom from 
 discomfort are not to be despised. 
 
 OPERATIONS ON THE ABDOMEN. 
 
 Laparotomy, or Abdominal Section, is a general term used to 
 describe any operation which involves opening the peritoneal cavity.^ 
 Definite operations are described more accurately by specific names, 
 such as gastro-enterostomy, cholecystectomy, entero-anastomosis, etc. 
 These terms will be defined in the proper place. They are sufficiently 
 descriptive of the operation when they stand alone, and it is not 
 necessary to complicate them by the prefix laparo- as is done by some 
 surgeons; though all such operations include that of laparotomy. 
 
 Abdominal Incisions. — In planning an incision through the abdomi- 
 nal wall, the surgeon must have in mind not only ready and sufficient 
 exposure of the abdominal viscera concerned in the operation, but also 
 must endeavor to inflict as little injury as possible on the structures 
 through which he cuts. There are three things to be considered in 
 this connection — the bloodvessels, the muscles with their aponeuroses, 
 and the motor nerves. 
 
 The hlood-supply is so free that injury or ligation of any one of the 
 main arterial trunks entails no danger of sloughing; but such injury 
 should be avoided whenever possible because time is lost in checking 
 the hemorrhage, and the wound is more liable to become infected if 
 not kept dry. The deep epigastric artery is the most important; 
 the superior epigastric is much smaller; and the deep circumflex iliac 
 is not often encountered. 
 
 ^ Laparotomy is derived from lairapa the Greek word for the soft parts between 
 the ribs and pelvis. Celiotomy is used as an equivalent by some writers, but is 
 considered less correct, as the Greek term KmAJa from which it is derived was 
 used for a cavity of any kind — a joint, the heart, as well as the abdomen. 
 
OPE RATIONS ON THE ABDOMEN 819 
 
 Muscles should 1)0 split in the course of tlieir fil)ros whenever possible. 
 Transverse section of muscle fibres is to be avoided; when this is 
 unavoidable, the muscle must be repaired by suture. The resulting 
 cicatrix in the muscle will resemble one of the lincfe transversae in the 
 rectus abdominis muscle; this will not impair much the muscle's con- 
 tractility, but it conii)licates the operation and is undesirable. The 
 fibres of the tliree oblique muscles of the abdomen cross each other's 
 course at various angles, and transverse division of one or two of these 
 muscles can be avoided only in small incisions, such as the grifliron 
 incision of INIcBurney (p. 820), where each muscular layer is split 
 in the direction of its fibres. Incisions through the rectus muscle 
 can be made of any length by splitting its fibres parallel to their 
 course. An incision through muscular tissue is preferable to one 
 through the linea alba or the linea semilunaris, because where several 
 layers of tissue are traversed, as in cutting through a muscle and its 
 sheath, much firmer union can be secured by suturing the wound in 
 several layers, than where only one aponeurotic structure is available. 
 
 The motor nerves are the most important of all structures to preserve, 
 since they are so small that they cannot be sutured if cut, and the 
 muscles supplied by them are paralyzed, and permit marked bulging 
 of the abdominal wall in spite of accurate repair of muscular and 
 aponeurotic structures by suture. These nerves are branches of the 
 lower intercostals (6th to 12th) and they run more or less transversely 
 forward from the intercostal spaces between the transversalis and 
 internal oblique muscles, giving off branches to these and the external 
 oblique; finally they perforate the posterior sheath of the rectus 
 muscle and supply it by numerous fine twigs. Any incision which will 
 divide these nerves is to be avoided whenever possible. An incision 
 through the semilunar line will cut the nerves supplying that portion 
 of the rectus muscle between the incision and the linea alba. Hence 
 any longitudinal incision, unless quite short, should be made as near 
 the linea alba as possible. If an incision is planned for any other 
 part of the abdominal wall, it should, so far as possible, run parallel to 
 and between two of the motor nerves. 
 
 Section of nerves, as mentioned above, results in bulging of the 
 abdominal wall from muscular paralysis (Fig. 807). This may entail 
 great disability; and unlike incisional hernia (p. 772), with which it 
 should not be confused, it cannot be cured by operation. All that can 
 be done is to apply some form of abdominal support, as in cases of 
 pendulous abdomen (p. 898). 
 
 For operations on the stomach, intestines, and female generative 
 organs surgeons usually employ a longitudinal incision splitting the 
 fibres of the rectus muscle close to the linea alba on the right or left, 
 whichever appears to give readiest access to the seat of disease. An 
 epigastric incision of course is used in stomach operations (Fig. 808), 
 and one in the hypogastrium for pelvic operations. For operations 
 on the small intestines the incision usually is made to the left of the 
 median line, just below the umbilicus; thus it may be extended upward 
 
820 
 
 ABDOMINAL SURGERY IN GENERAL 
 
 past the umbilicus without injuring the round ligament of the liver, 
 which lies to the right. 
 
 For opnations on the gall-bladder the usual incision is a longitudinal 
 one through the outer third of the right rectus muscle, from the costal 
 margin downward for four inches ; if more room is needed the incision 
 is extended obliquely upward along the costal border to the ensiform 
 process (Mayo Robson's ijicmon). Though this incision necessarily 
 divides a number of motor nerves the resulting disability is much 
 less than when an incision of similar length is used in the lower 
 abdomen, where the tension is greater. 
 
 Fig. 807. — Bulging of right side of 
 abdomen from paralysis of motor 
 nerves as result of long incision in right 
 rectur muscle. Episcopal Hospital. 
 
 Fig. SOS. — Incision for perforated duo- 
 denal ulcer. Cicatrix three and a half 
 inches. Suprapubic stab wound for drain- 
 age. Episcopal Hospital. 
 
 For operations on the appendix a lateral incision is employed. If 
 only a small incision is required, the muscle-splitting or gridiron incision, 
 introduced in 1893 by ]\IcBurney, is preferred by many operators.^ It 
 is centred over McBurney's point, which is "from one and a half to 
 two inches" from the right anterior superior iliac spine, and on a 
 line from that point to the umbilicus. The skin incision is made 
 parallel to Poupart's ligament, and the aponeurosis of the external 
 oblique is divided in the same direction, parallel to its fibres. The 
 fibres of the internal oblique are thus exposed. They run nearly at 
 right angles with the previous incision, and are split in this direction. 
 The fibres of the transversalis at this point run in the same direction 
 as those of the internal oblique, and are split with them in the direc- 
 tion of their course. The peritoneum is opened by an incision 
 parallel to that through the skin. This gridiron incision cannot 
 well be made more than tliree or four inches long. ]\Iany surgeons 
 expose the appendix by a longitudinal incision splitting the outer 
 
 * It had been used previoush- by L. L. McArthur. 
 
OPERATIONS ON THE MihOMEN .S21 
 
 fibres of the right rectus niusele; tliis has been calleti Dcaccru incision; 
 he calls it the " simple incision." Or, after opening the anterior sheath 
 of the rectus and displacing the fibres of this nniscle toward the median 
 line (passing around the lateral border of the muscle without splitting 
 its fibres), the posterior sheath of the rectus, together with the trans- 
 versalis fascia and peritoneum, may be incised, as proposed by Battle 
 in ISi)'), by Jalaguier and by Kammerer in 1<S<)7, and })y Ix^nnander in 
 1S*)S. Both this and Deavcr's incision necessarily divide a number 
 of nerves to the rectus muscle unless the incision is short. For this 
 reason I prefer the transverse incision of G. (i. Davis (1900), which 
 is described at p. So4. 
 
 Making the Abdominal Incision. — ^The skin and superficial fascia are 
 divided down to the aponeurotic layer (external oblique aponeurosis, 
 anterior sheath of rectus). Bleeding-points are clamped. The aponeu- 
 rotic layer is then divided throughout the length of the incision. Do 
 not forget that in the lower al)dominal wall the aponeurosis of the 
 external oblicjue does not blend with the rectus sheath at the semilunar 
 line, but passes as a separate structure for some distance toward the 
 meciian line before blending. Therefore an incision in the lower abdo- 
 men just to the median side of the semi-lunar line must divide the exter- 
 nal ()l)lique aponeurosis and the rectus sheath as separate structures 
 before the muscular fibres of the rectus will be exposed. When the 
 muscular fibres are exposed they are to be split parallel to their course. 
 This is best done by the handle of the scalpel, followed by the fingers 
 of the surgeon. In the hypogastric region the rectus fibres should be 
 split from below upward, and in the epigastric region from above 
 downward, so as in each case to brush aside rather than break oft' the 
 branches of the epigastric arteries w^hich run in the directions named — 
 from the epigastrium down, and from the hypogastrium up. When the 
 transversalis fascia and peritoneum are exposed they should be caught 
 up in two hemostats, applied about a centimeter apart, and should 
 be drawn away from the underlying viscera; then the surgeon should 
 divide these structures cautiously, with the flat (not the point) of the 
 knife, held sideways (Fig. 809). If the peritoneal cavity is not opened 
 at once, another hold should be taken of the intervening tissues, and 
 thus the surgeon should cut dow^n layer by layer until the peritoneum 
 has been opened. As soon as this is accomplished, the scalpel is laid 
 aside, and the peritoneal opening is enlarged by a blunt pointed 
 scissors passed on the finger as a guide. The peritoneum is opened 
 to the full length of the abdominal wound. 
 
 Closing the Abdominal Incision.— The cut margins of the peritoneum 
 (including the transversalis fascia, and where present the posterior 
 sheath of the rectus) are caught in hemostats, and drawn into the 
 wound until visible. The abdominal viscera are kept from protruding 
 by the insertion of a gauze pack. Then the peritoneum is closed \yith 
 a continuous catgut suture, applied so as to evert the peritoneum into 
 the wound (Fig. 810). This brings endothelial surfaces together, 
 favors rapid union, and lessens the chances of omentum becoming 
 
822 
 
 ABDOMINAL SURGERY IN GENERAL 
 
 Fig. 809. — Incising the parietal 
 peritoneum. 
 
 Fig. 810. — Suturing parietal peritoneum 
 (Deaver and Ashhurst.) 
 
 Fig. 811. — The "splint sutures" have been inserted, and their ends are clamped. The 
 anterior sheath of the rectus is being sutured. (Deaver and Ashhurst.) 
 
OPERATIONS ON TIIK ABDOMEN S23 
 
 adluTi'iit to the alxloiiiiiiiil surfiur ol' tlu" cicatrix. Before the hist 
 peritoneal suture is drawn ti^lit, tlie gauze pack is removed. 
 
 If the wound is large or if the patient is very fat, several "relaxa- 
 tion" or "splint sutures" are next inserted; these are interrupted 
 sutures of non-ahsorhable material, silkworm gut, linen, or wire. 
 Each splint suture is i)assed from the skin surface down through all 
 structures of the ahdominal wall to the peritoneum (which has already 
 heen sutured) across the wound, and out through all structures of the 
 ahdominal wall on the other side, to the skin surface. None of these 
 sutures is tied at this time. 
 
 Next the aponeurotic layer is sutured with a continuous stitch of 
 chromic catgut (Fig. SU ). The split muscle fibres fall together naturally 
 and do not require a separate suture. If there is much subcutaneous fat, 
 a continuous suture of plain catgut may be used to appose it. Finally 
 the splint sutures are pulled taut and tied, not with very much tension, 
 but just tight enough to obliterate all dead spaces in the wound. A 
 few superficial skin sutures, may be required to secure accurate closure. 
 If the patient is not fat, and the wound small, the splint sutures may 
 be omitted. 
 
 In wounds which are drained it is safer to use interrupted sutures 
 tliroughout, so that should one stitch become infected it may be 
 removed without destroying the entire row of sutures. 
 
 General Technique of Abdominal Operations.— There are so many 
 technical points that are common to difi'erent abdominal operations, 
 that it is convenient to describe them together. I shall consider here 
 preparation for operation, and after care; as well as intestinal localization, 
 methods of intestinal suture, intestinal resection, and entero-anastomosis. 
 In all abdominal operations the parts especially concerned in the 
 manipulations are walled off from the rest of the viscera by gauze 
 "packs" or "pads." These are made by stitching together a number 
 of layers of gauze (four to six thicknesses is sufficient) so as to give 
 the packs a certain bulk, and prevent ravellings from escaping into 
 the wound. These packs are made of convenient sizes; for a major 
 laparotomy, they should be about 8 by 14 inches; for a minor lapa- 
 rotomy they may be much smaller. Most important is it not to allow 
 one of the gauze packs, or a sponge, or an instrument, to^ become lost 
 in the wound. Such accidents sometimes occur, but with care and 
 system are avoidable in almost all cases. It is best to have a tape 
 attached to one corner of each pack, and to leave this tape hanging out 
 of the wound, clamped by a hemostat; if a piece of gauze never is placed 
 entirely within the abdomen, it is not likely that it will slip in unper- 
 ceived. Some operators employ a continuous roll of gauze, which is 
 unrolled only as it is inserted into the abdomen. Many surgeons use 
 these packs, and all gauze employed within the abdomen, only after 
 it has been moistened in hot saline solution. I prefer to keep them dry. 
 Preparation of Patient for Abdominal Operation. — Unless immediate 
 operation is demanded, as in emergency cases, the preparation of the 
 patient should begin at least twenty-four hours before the time set 
 
824 
 
 ABDOMINAL SURGERY IX GENERAL 
 
 for the operation. It is well that he should learn to pass his urine 
 while lying on the flat of his hack (Atlee); it may save him much dis- 
 comfort after operation. Other general preparation is the same as 
 for any major operation. The intestinal tract should be well cleared 
 by a purge and this should be administered sufficiently early on the 
 day before the operation for it to act before night, so that the patient's 
 sleep may not be disturbed. On the day of operation, and at least 
 two hours before the time set for operation, the patient should be 
 given an enema of warm soapsuds. Even in emergency cases it often 
 is well to administer an enema just before operation. 
 
 Fig. 812. — Gauze packs, for a major laparotomy; with "sponge forceps." 
 
 The abdomen should be shaved, including tlie pubic hair, and should 
 be washed ^ith green soap, rubbed with alcohol (GO per cent.), and with 
 bichlorid of mercury (1 to 2000). Tlien a dry sterile dressing should be 
 applied. This preparation is best done in the evening of the day before 
 operation; unless done at least three or four hours before operation, the 
 skin will not be sufficiently dry at the time of operation for the use of 
 iodin to be effectual (p. 141). If iodin is not used, the entire abdomen 
 should be washed again, after the patient is etherized, as at the first 
 preparation. In emergencies it is suflBcient to paint the abdomen 
 (previously shaved dry) with 3 per cent, iodin twice, allowing the 
 first coat of iodin solution to become thoroughly dried before the second 
 is applied and waiting until the second has dried before making the 
 incision. 
 
 On the evening before operation the patient should eat only a 
 light, semi-solid meal Only cooked (sterile) food should be taken for 
 at least two days before operation. The mouth and teeth should be 
 
OPERATIONS ON THE ABDOMEN 825 
 
 carefully cleansed. On the day of operation notliinj^ hut water sliould 
 he allowed, unless the operation is to he late in the afternoon. Then 
 a little li(iuid, preferahly not milk, should he j^iven for hreakfast. 
 \Yater may he taken until two hours hefore operation, hut not in 
 excessive quantities. 
 
 After-treatment in Abdominal Operations. — \'er>' little except careful 
 nursing is required in uncoinpHc-ated eases. If there is no vomiting, 
 a drachm of hot water (not luke-warm) may he given every few 
 minutes after eight to twelve hours. I am quite convinced that 
 really hot water is less apt to cause nausea than is ice or ice-water. 
 After eighteen to twenty-four hours small cpiantities of liquid diet 
 may be given; soft diet may he l>egun on the third or fourth day. 
 If the stomach has been the seat of operation mouth-feeding should 
 not be begun for from twenty-four to thirty-sLx hours after operation. 
 Vomiting is treated by total abstinence from mouth-feeding; by 
 sitting the patient up in bed; by the administration of a glass of hot 
 water; and finally by lavage. The treatment of peritonitis has already 
 been considered (p. 810). 
 
 The surgeon should not be in too great a hurry to have the patient's 
 bowels moved. Unless they move spontaneously, an enema may be 
 given on the third or fourth day. Owing to the pre-operative catharsis, 
 and the abstinence from food after operation, it is futile to expect a 
 free evacuation any sooner. Cathartics should not be given after 
 operation unless the enema proves ineffectual. Calomel in divided 
 doses, followed by a saline purge, usually is preferred. 
 
 The patient may be turned on his side (this does not mean that he 
 may turn himself) on the second day after operation if he desires it. 
 He should be made comfortable. If there is peritonitis he w^ill be in 
 the sitting posture (Fig. 805) and will not need to be turned over to 
 ease his back. 
 
 It is not well for the patient to leave bed until several days after 
 the sutures have been removed. Rarely should an abdominal patient 
 spend less than two weeks in bed. If the incision was large, or the 
 operation very extensive, it may be advisable for the patient to remain 
 in bed three weeks or longer. Only the very old should be hurried 
 out of bed; and even they, if they can be made comfortable in a sitting 
 position in bed, do just as well in bed as in a chair. 
 
 Intestinal Localization. — Often during the course of an abdominal 
 operation it becomes important to distinguish large from small bowel, 
 or even to identify more or less accurately different areas of the latter 
 as belonging to the upper jejunum, the middle of the small gut, or 
 the lower ileum. In cases of peritonitis or intestinal obstruction, the 
 small intestine may be so distended as to equal or exceed the size of 
 the colon, so that mere size is no criterion. In many cases the longi- 
 tudinal bands on the colon may be recognized, or even the sacculation 
 of the large intestine; but inflammatory changes or distention may 
 obscure such means of identification. The large intestine in fat adults 
 is covered by epiploic appendages; but in children and emaciated 
 
826 ABDOMINAL SURGERY IN GENERAL 
 
 adults these are absent. The safest and most constant distinction is 
 the attachment of the intestine to the posterior abdominal wall by 
 its mesenteries (Da Costa, 1894). The small intestine is attached 
 by its mesentery obliquely across the lumbar spine: the coils of small 
 bowel rarely can be brought very far laterally in the abdominal cavity, _ 
 but usually occupy its middle portion. The large intestine is attached 
 to the posterior abdominal wall on the right and left of the abdomen, 
 and transversely above. If all the intra-abdominal structures are 
 pushed away from the right side by the use of gauze pads, the bowel 
 which it will be impossible to push away, will be the cecum and ascend- 
 ing colon. In inserting the hand, if the fingers be made to follow the 
 peritoneum on the right across the flank, into the loin, and toward 
 the median line, the first bowel they encounter attached to the pos- 
 terior abdominal wall, will be the ascending colon. The same con- 
 dition of affairs exists on the left side : the descending colon and the 
 sigmoid have their posterior attachments further to the left than any 
 of the intestines, and after all the movable bowels have been packed 
 away from the left side, the immovable intestine, which remains 
 relatively fixed, will be the descending colon or sigmoid. The sigmoid 
 often has a long mesentery, and the sigmoid loop may prolapse into a 
 right inguinal incision. The same is true of the transverse colon, 
 which may be easily accessible from either iliac region or the hypo- 
 chondrium. But the transverse co on is easily distinguished from other 
 portions of the large bowel because it has the great omentum attached 
 to it. The sigmoid and cecum are readily distinguished from each 
 other by their mesenteric insertions. 
 
 The mesentery of the small intestine, as already noted, crosses the 
 lumbar spine obliquely, beginning above on the left, and ending at 
 the cecal region on the right. The direction in which a coil of small 
 bowel is running {i. e., which end is nearer the duodeno-jejunal junc- 
 ture) can be ascertained by paying attention to the attachment of its 
 mesentery. The coil of bowel to be investigated should be withdrawn 
 from the abdomen, spread out, and untwisted, until the fingers can 
 follow the mesentery down to its origin or root along the lumbar 
 spine. If the bowel is not rotated on its mesentery, it is evident that 
 it is running in the same direction as the root of the mesentery, and 
 hence that its upper (duodenal) end is nearer the epigastrium than is 
 its lower (cecal) end. The upper end of the jejunum is readily found 
 by lifting the great omentum and with it the transverse colon out of 
 the abdomen, and turning these structures upward on the patient's 
 thorax. This makes the transverse mesocolon taut, and the jejunum 
 is seen emerging from its lower layer just to the left of the spinal 
 column. This is the duodeno-jejunal juncture. The duodenum here 
 is retroperitoneal, and the first intraperitoneal coil of gut is the origin 
 of the jejunum. This is an important landmark in gastro-jejunostomy. 
 The lower end of the ileum, or the ileo-cecal juncture, is readily found, 
 by running the fingers upward along the external iliac vessels as they 
 lie at the brim of the true pelvis. The structure which arrests 
 
INTESTIXA L L()( 'A LIZA 'HON 827 
 
 X\w fiiif^tTs in till' lu'if^hhorliood of the ri^^lit sacro-iliac joint, will Ik- the 
 tiTniination of tlir inesoiitery of the ileum where this passes into 
 the (reuni. With a little praetiee it is not diffieult to scoop up into the 
 wound, on the finger tips, the ileo-eecal loop, and thus to bring the 
 
 Fig. 813. — -The mesenteric arteries in the upper portion of the jejunum. There 
 are only primary vascular loops, and the vasa recta are long. 
 
 appendix vermiformis into view\ Monks (1903) conducted studies 
 in the hope of being able to diflferentiate at operation betw^een dif- 
 ferent portions of the jejuno-ileum, without the necessity of tracing 
 the entire small intestine dowmvard from its origin or upward from its 
 termination. Chief reliance is placed on the arrangement of the 
 
 Fig. 814. — The mesenteric arteries in the middle of the jejuno-ileum. Secondarj' 
 loops are well-developed, and the vasa recta are shorter. 
 
 viesenieric bloodvessels. High in the jejunum there are only primary 
 vascular loops, with perhaps an occasional secondary loop, and the 
 vasa recta are from 3 to 5 cm. long (Fig. 813). Midw^ay, sa}' at ten 
 feet from either end, the secondary loops are a prominent feature of 
 
828 
 
 ABDOMINAL SURGERY IN GENERAL 
 
 the mesenteric vessels, and the vasa recta are shorter (Fig. 814). In 
 the lower ileum the vessels are much less easily distinguished, owing 
 to the deposition of fat in the mesentery; the loops, if visible, are 
 much more complex, and the vasa recta are short and irregular (Fig. 
 815). The upper jejunum is larger in diameter, its walls are thicker, 
 and often the valvulte conniventes are palpable, or they may be visible 
 by transmitted light. The lower ileum is smaller, and its walls are 
 thinner. 
 
 Fig. 815. — In the lower ileum the mesenteric bloodvessels can hardly be distinguished, 
 owing to the deposit of fat. The preparations shown in Figs. 81.3, 814, and 815 are from 
 the laboratory of operative surgery in the University of Pennsylvania. 
 
 Intestinal Sutures. — The underlying principle in suture of organs 
 covered with peritoneum is to bring serous surfaces into contact. 
 This principle appears to have been introduced by Jobert de Lamballe 
 in 1824. It is analogous to the principle adopted in surgery of the 
 vascular system (Chapter X), always to bring intima into contact 
 with intima. Such apposition, both of the intima which lines blood- 
 vessels and of the peritoneum which covers the abdominal viscera, 
 results in much more rapid and certain union than where the muscular 
 or fibrous layers of these structures are sutured without bringing their 
 serous surfaces into contact. 
 
 Any suture which brings serosa into contact with serosa may be 
 called a sero-serous suture. There are many varieties of this suture 
 in use at the present day, to which the names of various surgeons 
 have been attached. As already mentioned, this principle was used 
 by Jobert in 1824; but in 1826 its application was simplified by Lem- 
 bert, and to this day an interrupted sero-serous suture is known as a 
 Lembert suture (Fig. 816). If the suture did not hold well he included 
 tissues down to the mucous coat of the bowel, and Halsted, in 1887, 
 renewed this injunction. It is said that it is easy to tell by the sensa- ' 
 tion imparted to the surgeon's hand, when the needle has caught up 
 the tough submucous tissue. As a matter of fact the needle often, if 
 not indeed usually, penetrates all the coats of the intestine; and this 
 makes no difference so long as no fecal leakage occurs along the needle 
 
IN TES TINA L iSVT UREA'S 
 
 .S29 
 
 track. This is prcxciiti'd hy tlic use of (1) rouiid-poiiitcd lurdk's, 
 and (2) linen celluloid thread (I'agenstecher's suture, !!)()()), wliich 
 ])()ssesses no capillarity. This suture material becomes encapsulated 
 and remains })ernianently. 
 
 For additional security in intestinal wounds, and especially to check 
 bleeding; from the cut niaruins of the bowel, it is the rule to enij)Ioy 
 also a through-and-through suture, which passes through all the coats 
 of the intestine. This is inserted before the sero-serous suture, is 
 
 Fig. 816. — Perforation of the bowel, Ijeinfj; 
 clos(!d hy three Lembert sutures. 
 
 Fig. 817. — a, Czeruy-Lemljert suture; 
 b, Albert-Lembert suture. (See the text.) 
 
 knotted within the lumen of the bowel, and should be of absorbable 
 material so that it will ulcerate out into the intestinal canal when 
 union is firm. Chromic catgut (No. or No. 1) is the best material. 
 The principle of the through-and-through suture knotted within the 
 lumen of the bowel we owe to Albert. A diagram of the Albert- 
 Lembert suture is shown in Fig. 817, b. Czerny's suture did not 
 penetrate the mucosa, and was not knotted within the bowel (Fig. 
 817, a). 
 
 Fig. 818. — Gely's suture. 
 
 Fig, 819. — a, The first points of a Gely 
 suture, used to close a puncture, b, a 
 purse-string suture, used to close a per- 
 foration. 
 
 Suture of Punctures and Perforations. — A mere puncture may be 
 inverted by a couple of Lembert sutures (Fig. 816) or by the first 
 points of a Gely suture (1844) (Fig. 818). A perforation usually may 
 be closed by a purse-string suture (Fig. 819, 6), but if it is large it 
 must be sutured as a wound in a direction either transverse or parallel 
 
830 
 
 ABDOMIXAL SURGERY IN GENERAL 
 
 to the long axis of the intestine, whichever puckers the bowel less. 
 As there seldom is bleeding from the edges of a perforation it is not 
 usually necessary to use a through-and-through suture, the sero-serous 
 suture being sufficient. 
 
 Suture of Incisions or Wounds. — Gunshot wounds resemble perfora- 
 tions and require the same treatment. Ruptures, lacerated and 
 incised wounds, especially operation wounds, usually require first 
 a through-and-tlirough suture to check hemorrhage. This may be 
 
 Fig. 820. — Closure of an intestinal 
 wound by a continuous through-and- 
 through suture. The knots lie within 
 the lumen of the gut. 
 
 Fig. 821. — Continuous sero-serous suture 
 (Dupuytren's suture). 
 
 either interrupted or continuous. The needle is entered at one end 
 of the incision, from the mucous surface, emerges on the peritoneal 
 surface, crosses to the opposite side of the incision, and there again 
 penetrates all the coats of the bowel from the serous to the mucous 
 surface. It is then knotted; the knot thus lies within the lumen of the 
 bowel. If an interrupted suture is desired, both ends of the thread 
 are cut short, and other sutures introduced about one-half a centi- 
 meter apart until the wound is closed. If a continuous suture is pre- 
 ferred, only the free end of the thread is cut short, and the needle is 
 
 Fig. 822. — Right-angled sero-serous suture of Cushing. 
 
 re-introduced on one side of the wound from its mucous surface, and 
 traversing all the coats of the bowel, emerges on the peritoneal sur- 
 face. The needle is then carried across the wound to its opposite lip; 
 here enters the serous surface of the bowel, traverses all its coats, and 
 emerges on the mucous surface. This completes the second stitch, 
 and the thread is then drawn taut, carefully inverting the lips of the 
 wound as this is done. Each similar stitch is pulled taut until the 
 other end of the wound is reached, when the suture is knotted and the 
 
INTESTINAL RESECTION 
 
 831 
 
 knot is allowed to retract within the lumen of the bowel (Fig. 820). 
 To reinforce this throuiih-and-tiirouKh suture, a coniinuous scro-scrous 
 suture (known also as i)upuytren's suture) is applied (Fig. S21). Any 
 point which seems weak may be reinforced again by an interrupted 
 suture. When there is much tension on the parts a sero-serous suture, 
 inserted as shown in Fig. S22, usually holds better; it is known as the 
 righi-auyird srro-scwus suture (also by the name of Ilayward W. 
 Gushing, 1889). Or a mattress suture, either interrupted (Fig. S23) 
 or continuous (Fig. S24) may be employed; this is known })y Ilalsted's 
 name (1887). 
 
 Fig. 823. — Interrupted mattress suture. 
 (Deaver and Ashhurst.) 
 
 Fig. 824. — Continuous mattress suture- 
 (Deaver and Ashhurst.) 
 
 Intestinal Resection.— When it is necessary to resect a portion of the 
 intestinal canal, the mesentery is first tied off. This is done by a 
 series of interlocking ligatures applied about an inch from the intes- 
 tinal attachment of the mesentery, and never over quite as wide an 
 area as the length of gut to be removed, for fear of endangering its 
 vitality. The gut above and below the diseased area is then double 
 clamped: suitable clamps, with their blades covered by rubber tubing, 
 introduced into surgery by Rydygier (1881), and popularized by 
 Doyen (1900), may be applied to healthy bowel, and if clamped only 
 tight enough to appose the mucous surfaces may remain in place for 
 an hour or more without inflicting any injury. These clamps should 
 have light, elastic blades, which meet at their tips before the bodies 
 of the blades come together (Fig. 825). They prevent fecal extrava- 
 sation and also serve the purpose of temporary hemostasis, like the 
 elastic band of Esmarch used in amputating. In emergency pieces of 
 tape may be tied around the bowel. 
 
 Such clamps should be applied to the healthy bowel an inch or more 
 above and below the proposed limits of resection. Any ordinary clamp 
 forceps are then applied at the limits of the diseased area, w^hich is thus 
 cut at each end between two pairs of clamps (Fig. 826), so that no 
 fecal extravasation occurs. 
 
 The subsequent procedure depends upon whether it is desired to 
 restore the continuity of the intestinal canal by anastomosis, or to 
 establish [a false anus in the wound. The best way to establish a 
 false anus after intestinal resection is to suture the two coils of bowel 
 together like a double-barrelled shotgun—" en canon de jusil," as the 
 
832 
 
 ABDOMINAL SURGERY IX GEXERAL 
 
 French call it. This is easily accomplished by a few sero-serous 
 sutures. Then the circumference of each intestinal coil is sutured 
 to the parietal peritoneum, leaving about an inch of each gut pro- 
 truding from the wound. The clamps used for resection may be left 
 
 Fig. 82.5. 
 
 -Clamps used in gastric and intestinal surgery. Note the form of the blades; 
 in the upper (three-bladed) forceps the rubber tubing is in place. 
 
 on the protruding ends for a few days (or until the peritoneal cavity 
 is shut off by adhesions), if there is no urgent need to secure a fecal 
 evacuation; or the ends may be simply ligated and be left to open 
 themselves when the slough separates. Other methods of forming a 
 
 Fig. 826. — Intestinal resection. After the mesentery has been ligated and cut close to 
 the bowel, the resection clamps are appUed, and the diseased bowel is cut away. 
 
 false anus are discussed at p. 914; and the treatment of this condition 
 is considered at p. 894. 
 
 Intestinal Anastomosis. — This may be accomplished by uniting the 
 gut end-to-end (circular enterorrhaphyj ; or, after closing the open ends 
 
INTESriNA L ANASTOMOSIS 
 
 833 
 
 of tlic intestines, tliese may he plaeed side by .side and a lateral anas- 
 tomosis may be establislicd (X. Senn, 1889). By an implantation is 
 understood an operation in which the end of one bowel is sutured into 
 the side of another, mnoli as the ileum is implanted into the cecum. 
 End-to-end Anastomosis.— The rubber-covered clamps employed 
 durinsj; he intestinal resection are left in place. By bringing? them 
 parallel to each other, the ends of the gut are approximated; these 
 then look at the surgeon like a double-})arrelled shot-gun. This brings 
 four layers of intestinal wall to view, two of which are apposed. 
 
 Fig. 827. — Encl-to-ond aimstoinosis. The 
 through-and-through suture has been started. 
 
 Fig. 828. — End-to-end anastomo- 
 sis. Passing the through-and-through 
 suture at the mesenteric attachment. 
 
 1. First, a continuous through-and-through suture of cliromic 
 catgut is applied: this is begun by introducing the needle from the 
 mucous surface of that coil of gut on the operator's right, at the anti- 
 mesenteric point. The needle is pushed through the apposed intes- 
 tinal walls from the lumen of one gut into that of the other, where it 
 emerges on the mucous surface, having in its course traversed all 
 intervening layers of both guts: of the first coil from the mucous to the 
 serous, and of the second coil from the serous to the mucous surface. 
 The first stitch is then tied, the knot coming within the lumen of the 
 bowel. The end is left long. The suturing is then continued (Fig. 
 827) toward the mesenteric attachment, and when this is reached the 
 suture is passed as indicated in Fig. 828. The suture is continued around 
 the margin of the gut, always passing from the mucous to the serous 
 surface of the first coil and from the serous to the mucous siu-face of 
 the second coil of bow^l. When the point of beginning is reached at 
 last, the suture is terminated by knotting it to the original end, which 
 was left long for this purpose. When both ends are cut short, the knot 
 disappears into the lumen of the bowel. 
 
 2. The clamps may then be removed, and the operation is com- 
 pleted by passing a continuous sero-serous suture around the entire 
 anastomosis, thus reinforcing the through-and-through suture. 
 
 3. The mesentery will become redundant when the intestinal ends 
 are approximated; its free border may be stitched to the anastomosis. 
 
 53 
 
834 
 
 ABDOMINAL SURGERY IN GENERAL 
 
 ]\Iaunsell (1892) thought it facihtated the operation of circular 
 enterorrhaphy to evaginate the divided ends through a longitudinal 
 incision in one of the coils of intestine. After suture of the divided ends 
 has been thus completed, from their mucous surface, they are replaced, 
 and the intestinal incision through which they were withdrawn is 
 closed. A partial intussusception of the sutured ends remains (Fig. 
 829). 
 
 M. E. Connell (1892) advocated only interrupted mattress sutures, 
 penetrating all the coats of the bowel, and tied on their mucous 
 surface. 
 
 Fig. 829. — Maunsell's method of circular enterorrhaphy. a, the incision in one coil 
 of intestine; b, the open ends of both coils evaginated through this incision, to facilitate 
 suturing; c, the operation completed. 
 
 t/ Lateral Anastomosis. — The open ends of the resected bowel must 
 first be closed. If the limien of the gut is small, it is sufficient to apply 
 a ligature in the groove made by a crushing clamp, as in the operation 
 of appendicectomy (p. 856) and to invert this ligature by a purse- 
 string sero-serous suture. When the guts are to be left in or near 
 the wound after the lateral anastomosis has been completed (as in 
 some cases of resection for strangulated hernia), it is sufficient to apply 
 a strong ligature, as above described, without a secondary inverting 
 purse-string suture. Thus time is saved. In most instances, however, 
 and especially where the lumen of the resected gut is of large size, 
 it is safer to close the end of the bowel by two layers of sutures, the 
 first being a continuous tlirough-and-through suture of chromic catgut, 
 and the second a linen sero-serous suture. 
 
 Lateral anastomosis should be made in an iso-peristaltic direction 
 (Fig. 830); though where afferent and efferent loops are sutured 
 together en canon de fusil, and an anastomosis is subsequently estab- 
 lished, the antiperistaltic direction of the anastomosis appears to make 
 little difference (Fig. 831). 
 
IN TKSTINA L A NA STOMOSIS 
 
 ^^r^ 
 
 The formation of n lateral anastomosis is nnicli facilitated bv the 
 use ot rnl.hcr-covcro.l intestinal clamps. The three-bluded "Roosevelt 
 elamp, or one ol snnilar pattern, is very convenient (Fig. 825) The 
 
 ) 
 
 _j 
 
 Fig. !S30. — Lateral anastomosis with 
 intestinal coils in iso-peristaltic relation. 
 
 Fig. 831. — Lateral anastomosis 
 with intestinal coils in anti-peris- 
 taltic r(>hiti()n. 
 
 
830 ABDOMINAL SURGERY IN GENERAL 
 
 clanij) should be applied so as to embrace a considerably greater area 
 of bowel than that concerned in the anastomosis. The anastomosis 
 is made on the free (antimesenteric) border of the intestinal loops. 
 
 1. The first step consists in the insertion of a continuous linen sero- 
 serous suture close to the median blade of the clamp, for a distance 
 a little longer than the size of the proposed intestinal opening, say 
 about 8 to 10 cm. This suture is begun at one end of the proposed 
 intestinal opening, where it is knotted, the free end being left long; 
 it is continued in a straight line to the other end of the proposed anas- 
 tomosis, uniting the two coils of intestine, as indicated in Fig. S.32. 
 When this point is reached the suture is not cut, but the needle, still 
 threaded, is laid aside temporarily, to be used again before the close 
 of the operation. This needle and thread will be referred to as the 
 sero-serous suture. 
 
 2. The surgeon then makes a longitudinal incision in one of the 
 coils of bowel, about one centimeter distant from and parallel to the 
 sero-serous suture already applied, and about 6 to 8 cm. in length. 
 This incision divides first the serous and muscular coats of the gut; 
 as these retract the mucosa pouts into the incision. The mucosa is 
 cautiously opened at one point, so as not to wound the opposite wall 
 of the bowel. Any discharge from the lumen of the bowel is wiped 
 carefully away. Then the opening in the mucosa is enlarged by 
 scissors to the full extent of the intestinal incision. If the mucosa 
 seems redundant, as is often the case in the small intestine, it should 
 be excised. The other coil of gut is then opened in a similar way for 
 an equal distance. There are now exposed in the wound two apposed 
 loops of intestine, each with a longitudinal incision in its antimes- 
 enteric border. Each of these incisions has two lips, an anterior and 
 a posterior. The two posterior lips are fairly close together, while 
 the anterior lips are some distance apart. For purposes of descrip- 
 tion it is convenient to apply definite names to these structures: we 
 may speak of the coil of bow^el on the operator's right as the first gut, 
 and that on his left as the second gut (frequently it is impossible to 
 know which of these is the afferent and which is the efferent loop); 
 each of these guts has an incision with an anterior and a posterior lip; 
 the posterior lips are closely apposed to each other. Where the 
 anterior and posterior lip of each incision join, is found the angle of 
 the incision; one angle is at the end of the intestinal incision away 
 from the operator {the far angle of the incision) and the other is at the 
 near end of the incision (the near angle of the incision) . 
 
 3. A through-and-through continuous suture of chromic catgut is 
 now to be inserted. The needle is entered at the near angle of the 
 incision in the first gut, from its mucous surface, and traverses all its 
 coats, emerging on its serous surface; it s then inserted at the near 
 angle of the second gut, passing from its serous to its mucous surface. 
 This stitch is then tied, the knot coming within the lumen of the bowel. 
 The end of the suture is left long; it should not be confused with the 
 end of the sero-serous suture (linen), which also was left long. The 
 
INTESTINA L A NASTO.VOSIS 
 
 837 
 
 throuf^h-and-throufili chrDinic f-atj^ut suture is continued away from 
 the operator, uniting tiie posterior lips of the intestinal ineisions, 
 as shown in Fig. So3, until the far angk-s of the incisions are reached. 
 During this time the needle ;s passed always from tlie nuieous surface 
 of the first gut through all its coats to its serous surface, and imme- 
 diately into the serous surface of the second gut, emerging on the 
 mucous surface of the second gut. Then the thread is drawn taut; 
 the needle is carried hack to the side from which it started, and again 
 enters the mucous surface of the first gut, traverses all its coats to 
 emerge on its serous surface, and at once enters the serous surface of 
 the second gut, and, traversing all 
 its coats, emerges on its mucous 
 surface in the lumen of the second 
 gut. This is accomplished each time 
 by one push of the needle, which is 
 enabled to pass through the walls 
 of both guts "all at one bite," be- 
 cause the posterior lips of the intes- 
 tinal incisions are so closely approxi- 
 mated. When, however, the far 
 angles of the intestinal openings are 
 reached, it is no longer possible for 
 the needle to pass through the walls 
 of both guts all at one bite, but 
 it is necessary for it to be passed 
 tlirough each separately. But the 
 same method of suturing may be 
 continued: thus the needle always 
 enters the first gut from its mucous 
 surface and emerges on its serous 
 surface; it then is carried across 
 to the free margin of the second 
 gut (at its far angle or on its an- 
 terior lip), and always enters its 
 wall from the serous surface and 
 emerges on its mucous surface. 
 This is readily understood by refer- 
 ence to Fig. 833. This method of suturing is continued along the 
 anterior lips of the intestinal incisions toward the operator until 
 the near angles of the incisions are reached, when a complete cir- 
 cumference will have been traversed by the through-and-through 
 cliromic catgut suture, which is finally knotted to its original end, 
 which was left long for this purpose at the starting-point, the near 
 angles of the intestinal incisions. As this suture is being inserted in 
 the anterior lips these should be carefully inverted so as to ensure 
 accurate contact of their serous surfaces. If there is difficulty in 
 securing proper inversion of the anterior lips, it is a very good plan 
 to use for this part of the operation a continuous right-angled suture 
 
 Fig. 833. — Lateral anastomosis: the 
 through-and-through suture has united 
 the posterior lips of the intestinal inci- 
 sions, and the far end of these incisions 
 has been reached. 
 
838 
 
 ABDOMINAL SURGERY IN GENERAL 
 
 similar to the sero-serous suture of Gushing (Fig. 822), except that 
 here the right-angled suture should penetrate all the coats of the 
 intestine, leaving the loop of the suture always on the mucous surface 
 of the bowel (Fig. 834). This is known as C. II. Mayo's suture (1905). 
 It is nothing else than a right-angled through-and-through suture. 
 
 4. When the application of the through-and-through suture has been 
 completed, the rubber clamps may be released, but should not be 
 removed from their position, as they serve to keep the parts accessible 
 for the application of the final suture. This is a continuation of the 
 sero-serous suture first applied, the needle of which, still threaded, 
 
 was laid aside temporarily be- 
 fore the application of the 
 through-and-through suture 
 was commenced. This sero- 
 serous suture is now continued 
 over the inverted anterior lips 
 of the intestinal anastomosis, 
 further inverting them and 
 burying from sight the through- 
 and-through suture. The sero- 
 serous suture is finally arrested 
 at the near angle of the anas- 
 tomosis, where it is knotted to 
 its own original free end, which 
 was left long for this purpose. 
 The clamps are then entirely 
 removed ; the anastomosis is in- 
 spected on all sides, any weak 
 spot being reinforced by one or 
 two additional interrupted sero- 
 serous sutures. The intestines 
 are then replaced within the 
 abdomen. 
 
 The advantages of lateral over 
 end-to-end anastomosis are the 
 following: the opening may be 
 made of any desired size; there 
 is no mesenteric attachment to be included in the sutures, and no fear of 
 leakage at this weak point. The chief disadvantage is the additional 
 time required for its performance, when it is employed after intestinal 
 resection, because then it involves also closure of two ends of bowel. 
 After lateral anastomosis following intestinal resection the coils of 
 bow^l involved tend to straighten out, so that after some years little 
 or no trace of the anastomosis can be found, even when it was made 
 in an antiperistaltic direction. Lateral anastomosis I believe should 
 be preferred (1) whenever the large bowel is concerned, as this has a 
 relatively large extraperitoneal surface and, therefore, usually is not 
 well adapted for an end-to-end anastomosis; (2) in cases where the 
 
 Fig. 834. — Lateral anastomosis: the far 
 angles of the Intestinal incisions have been 
 sutured, and the anterior lips of the incisions 
 are now being united by the through-and- 
 through suture which is passed in a manner 
 similar to the sero-serous suture shown in 
 Fig. 822. 
 
INTESTINA L A NASTO.\f()SIS 
 
 S39 
 
 two coils of <jut to be anastoiiiosed dill'cT inuch in diainctcr, thoiiji:li hy 
 careful suture or by cutting the smaller intestinal loop ol)li(juely it is 
 possible to employ end-to-end anastomosis even under such circum- 
 stances; and (3) in cases where the intestinal walls arc altered from 
 inflannnatory changes, as in most cases of acute intestinal obstruction, 
 strangulated hernia, etc. Knd-to-end anastomosis I think is best 
 limited to resections of small intestine not undertaken in the presence 
 of acute disease. 
 
 I'lG. 835. — The Murphy button for intes- 
 tinal anastomosis; above, the female half; 
 below, the male half of the button. 
 
 Fig. 836. — Two coils of intestine 
 anastomosed by means of the Murphy 
 button. 
 
 Mechanical devices for intestinal anastomosis are not much used by 
 surgeons any more. The Murphy button, introduced by J. B. Murphy, 
 in 1892, is still the most popular in this country, as is the somewhat 
 similar contrivance of Jaboulay, in France, and Mayo Robson's bone 
 bobbin, in England. The Murphy button is a very ingenious contriv- 
 ance, made of metal, nickel-plated; it consists of two parts (Fig. 835), 
 one of which is inserted through a small incision into each of the loops 
 of bowel to be anastomosed, and is held in place by a purse-string 
 suture which puckers the bowel around the half of the button inserted. 
 The projecting shanks of each end of the button are then forced 
 together, the male within the female; the two halves of the button are 
 thus held together automatically by a spring. Serous surfaces are thus 
 brought into broad apposition (Fig. 836). The union may be reinforced 
 by a few interrupted sero-serous sutures. The button is provided with 
 a lumen in its centre, and if all goes well it ulcerates into the lumen 
 of the intestine in ten days or two weeks and is passed by rectum. 
 During the application of the button its lumen may be filled with 
 cocoa butter, which will prevent fecal extravasation temporarily, but 
 melts as soon as the intestines are returned to the abdomen. I have 
 never used any mechanical device in effecting intestinal anastomosis, 
 but believe the jNIurphy button better than any other such appliance. 
 It is particularly indicated where the parts concerned in the operation 
 
840 ABDOMINAL SURGERY IN GENERAL 
 
 cannot be brought into the wound so as to render accurate suture 
 possible, or where very rapid conclusion of the operation becomes 
 imperative. The chief danger from the use of the button is that its 
 mechanism may be defective, so that it may ulcerate out too soon, 
 allowing fecal extravasation and causing death from peritonitis. It 
 should be an invariable rule for the surgeon himself personally to test 
 the mechanism of the button thoroughly and several times before 
 the operation is commenced. Occasionally the button has caused 
 intestinal obstruction. 
 
 INJURIES OF THE ABDOMEN. 
 
 Subcutaneous Injuries. — These may affect the abdominal wall 
 only, or there may be visceral injury with or without injury of the 
 overlying structures. In almost all cases the injury is by direct vio- 
 lence, blunt force in the form of a blow, a kick, a fall, or a crush, being 
 applied to the abdominal wall. If the abdominal muscles are rigidly 
 contracted, the blow a glancing one, the force not very great, and the 
 viscera not distended or weakened by disease, only a contusion of the 
 abdominal wall may result. If the force is greater, rupture of the 
 abdominal wall may occur; this was referred to at p. 273. Rupture 
 of one of the abdominal muscles from voluntary contraction sometimes 
 occurs in cases of typhoid fever; I have seen one case, apparently of 
 this nature, complicating pneumonia. 
 
 When there is visceral injury it usually is because the abdominal 
 muscles have been taken off their guard, or because they are very 
 flabby and weak. Then the force need not be very great, especially 
 if the hollow viscera are distended or the solid viscera enlarged by 
 disease. In these cases no macroscopic evidence of injury to the 
 abdominal wall may be found. Visceral injury without injury of the 
 abdominal wall is much more frequent than rupture of the abdominal 
 wall without visceral injury. The gravity of the injury, as pointed 
 out at p. 181, depends largely upon the momentum of the vulnerating 
 body : a mere tap on the abdomen from a heavy swinging crane, or 
 block and tackle, will do much more damage than a smart blow with 
 a stick. Sometimes a fall inflicts injury by indirect violence, one of 
 the abdominal viscera being torn from its moorings by the jar when 
 the patient lands on his buttocks or feet; but this is very rare. 
 
 Most cases of abdominal injury occur in men during active adult 
 life, or in children. An irreducible hernia is an important predisposing 
 factor: not so much that the structures in the hernial sac are injured, 
 but because the intra-abdominal organs are held taut, and thus are 
 unable to escape from a crushing force. This was the case in two out 
 of five patients upon whom I have operated for subcutaneous rupture 
 of the abdominal viscera. 
 
 The intestinal trad is most often injured. Its more fixed portions 
 (duodeno-jejunal juncture, lower ileum and cecum) are most exposed 
 to injury. The injury may be a mere contusion, which may or may 
 
INJURIES OF Till': MiDOMEN S41 
 
 not terminate in <];anp;ron(' and perforation; rn])tnre may occnr; or the 
 howel may he torn loose from its nu'sentery. l{nj)tnres nsually oecur 
 on the anti-mesenteric horder of the gut, and seem to be caused by 
 over-(Hstention of the intestine with a resulting explosive injury, a 
 coil of gut being compressed so as to dam up its contents against an 
 obstruction, such as the ileo-cecal valve or a kink between adjacent 
 intestinal loops. A few cases of rupture of the large bowel ha\e been 
 reported from the injection of compressed air into the rectum. Rup- 
 tures of the stomach have occurred from too forcible lavage, and from 
 artificial distention with Seidlitz powders; this is especially to })e feared 
 in cases of gastric carcinoma, and in unconscious patients. Sponta- 
 neous rupture of the stomach has been reported as a result of vom- 
 iting, fermentative distention, etc. Complete transverse ruptures 
 occur oftenest at the duodeno-jejunal juncture. Crushes of the intes- 
 tine result from pressure between the body which inflicts the injury 
 and the sacral promontory or lumbar spine. In this way the lower 
 ileum is often torn loose from its mesentery. 
 
 The solid organs are less often the seat of injury than is the gastro- 
 intestinal tract. The spleen and liver are much more frequently 
 injured than is the pancreas, which is in a protected situation. The 
 liver or spleen may be penetrated by the fragments of broken ribs, 
 but usually the lesion is a rupture from diflfuse compression. The 
 rupture may be entirely subcapsular, or may extend to the surface 
 of the organ. 
 
 Symptoms and Diagnosis. — Often there is considerable shock; 
 usually there is vomiting; local pain causes shallow and thoracic 
 respiration. Pain is the most constant symptom, and where fecal 
 extravasation occurs it may be agonizing. The abdominal wall is 
 very rigid, and physical examination is unsatisfactory. 
 
 If there is only a severe contusion of the abdominal wall, without vis- 
 ceral injury, the general condition of the patient is not much afi'ected, 
 even at first, and it rapidly improves. The pain is not very great, 
 but tenderness and rigidity usually are very pronounced. It is very 
 difficult to exclude visceral injury certainly, and in most cases explora- 
 tory laparotomy is indicated. If there is a large niphire of the gastro- 
 intestinal tract, permitting fecal extravasation, the pain is extremely 
 severe; but if the rupture is very small it may be occluded by the 
 mucosa,^ and there may be comparatively little pain. Serious symp- 
 toms follow intra-abdominal hemorrhage even when there is no injury 
 of the gastro-intestinal tube. A significant symptom in cases with 
 visceral injury is a steady increase in the pulserate; usually the 
 temperature also rises, and leukocytosis develops. Later the signs 
 of peritonitis develop. If there is a rupture of one of the solid organs, 
 or of the omentum or mesentery, signs of internal hemorrhage usually 
 precede the onset of peritonitis. Emphysema of the abdominal wall 
 (a valuable but very rare sign), indicates rupture of a hollow viscus. 
 
 1 In all injuries sustained during life the mucosa is everted into the rupture; 
 this is not the case if the rupture takes place after death (Whitney). 
 
842 ABDOMINAL SURGERY IN GENERAL 
 
 The only certain way to exclude visceral injury is by exploratory 
 laparotomy, and usually this is postponed too long. 
 
 Ruptures of the gastro-intestinal tract almost always are due to injury 
 from the front. Apart from the very severe pain, mentioned above, 
 the occurrence of repeated vomiting, of widespread tenderness and 
 rigidity, or of blood in the stools, indicates injury of a hollow viscus. 
 
 Rupture of the liver is due to injury to the right hypochondriac 
 region or lower thorax. As noted above, fracture of the ribs may be 
 present, with puncture of the liver by a fragment. The rupture usually 
 is in the right lobe, involves the capsule of Glisson, and permits intra- 
 peritoneal hemorrhage. The chief symptoms are those of internal 
 hemorrhage. Jaundice may develop after several days. Rupture of 
 the gall-bladder or hile-ducts allows extravasation of bile, and peri- 
 tonitis develops early or late according to the infectiousness of the 
 bile. 
 
 Rupture of the spleen is most frequent in cases of malarial hyper- 
 trophy, and under such circumstances may occur from very slight 
 trauma, or even spontaneously. Other enlargements of the spleen 
 also predispose it to rupture. This occurrence during typhoid fever 
 is rare, and usually fatal. Rupture of the normal spleen usually is due 
 to severe injury directly over the left hypochondriac region, lower 
 thorax or loin; but if the spleen is enlarged it may be ruptured or torn 
 loose from its supports by indirect violence. 
 
 Rupture of the Kidney. — See p. 984. 
 
 Rupture of the Rladder. — See p. 971. 
 
 Treatment. — If there is reasonable doubt as to the presence of 
 visceral injury, the patient should be carefully studied for three or 
 four hours after the accident. If there is only contusion of the abdomi- 
 nal wall, distinct improvement usually occurs within this time. If no 
 improvement occurs, I believe exploration is imperative, even if the 
 patient does not seem to be growing worse. The mortality without 
 operation is 96 per cent. The earlier the operation the more chance 
 there is of its being successful; isolated case reports show that the 
 death rate after operation within twenty four hours of injury is about 
 55 per cent. The general mortality after operation, in consecutive 
 series of cases, is about 85 per cent. (Meerwein, 1907). Until operation 
 is done, the shock should be treated; and, after matcing a diagnosis, 
 morphin may be administered to allay pain. In cases of mere con- 
 tusion an ice bag or hot water bag locally may be soothing. After 
 operation, treatment as for peritonitis is indicated- (p. 810). 
 
 Operation. — Unless there are definite indications of the seat of the 
 lesion, a left paramedian incision should be made just below the 
 umbilicus. Do not let the intestines escape from the wound. If 
 there is free air in the peritoneal cavity, or if gastric or intestinal 
 contents are found, it is clear that the gastro-intestinal tract is 
 ruptured. If the abdomen is full of blood, it probably comes from a 
 solid organ or from the omentum or mesenteries. If the operation 
 has been delayed, the presence of recent adhesions, lymph, etc., will 
 
INJURIES OF Till': ABDOMEN 843 
 
 serve as a guide to the seat of rupture. If these are abseut, tlie iutes- 
 tine must he examined in detail, hej-iuuiug at the ileo-eeeal juncture, 
 and passing upward toward the duodenum. Not more than two or 
 tiiree feet of small intestine sliould he outside the abdomen at any 
 one time. Most ruptures are in the lower ileum. If active hemor- 
 rhage is found, this should be checked before anything else is done. 
 For this purpose it is best to pack all the intestines away first to one 
 side of the wound and then to the other and examine all structures 
 in turn on the right and on the left, from the spinal gutter forward 
 and from diai)hragm to pelvis. Eventration of the intestinal tube 
 does not facilitate the search; it is best to keep the intestines inside 
 the abdomen as much as possible. Do not hesitate to make your 
 incision large enough to facilitate rapid operating. 
 
 Intestinal Traci.—\ rupture of the antimesenteric border usually 
 can be repaired by suture, as described for perforations (p. 829); 
 resection of the intestine should be avoided if possible. A complete 
 transverse rupture should be treated by lateral anastomosis, or, as 
 a last resort, and only when the rupture is low in the intestinal tract, 
 by establishment of a false anus. At the duodeno-jejunai juncture, 
 where lateral anastomosis is impossible, end-to-end union should be 
 attempted; if this proves impossible, the duodenal end should be closed, 
 and the upper end of the jejunum united to the stomach by lateral 
 anastomosis (gastro-jejunostomy, p. 879). In ^Nloynlhan's case the 
 regurgitation of the bile and pancreatic juice into the stomach caused 
 no disability. Meerwein successfully supplemented this operation 
 by uniting a lower loop of the jejunum to the descending duodenum 
 (anterior antecolic duodeno-jejunostomy). If the intestine is torn 
 loose from its mesentery at any point, it should be resected; it will 
 be best then to fix the intestinal loops in the wound, en canon de 
 fusil (p. 834), after ligating their ends and establishing a lateral anasto- 
 mosis, as advised in cases of resection for strangulated hernia. Irriga- 
 tion should not be employed, even if there is fecal extravasation. 
 A large rubber or glass drainage tube should be carried to the floor of 
 the pelvis, and subsequent treatment should be conducted as in cases 
 of peritonitis. 
 
 Liver.— li injury of the liver is suspected, the incision should be 
 made through the upper right rectus. As the blood-pressure in the 
 liver is low, hemorrhage is not difficult to control if the site of rupture 
 is accessible. If possible, the injury should be sutured. Mattress 
 sutures of chromic catgut will hold in most cases, if they are not drawn 
 too tightly. If they cut out, they should be tied over strands of 
 catgut, used as the quills in the old-fashioned quill suture (Fig. 105). 
 If direct suture proves impossible, the omentum may be sutured into 
 the rupture, as a tampon, or gauze may be used. Blood-clots should 
 be scooped out of the pelvis and spinal gutters, or wiped up with 
 sponges; but irrigation is not advisable. The pelvis should be drained, 
 and subsequent treatment conducted as in peritonitis. The mortality 
 after operation is from 75 to 80 per cent. (Boljarski). 
 
844 ABDOMINAL SURGERY IN GENERAL 
 
 Spleen. — The incision is best made in the upper left rectus muscle. 
 The operative mortality is about 38 per cent., but many patients die 
 before operation can be undertaken. If the spleen is not much dis- 
 organized, it may be possible to suture the rent, or to tampon it, or 
 even to compress the spleen against the diaphragm by firmly applied 
 gauze packs; but suture is difficult, owing to the friability of the splenic 
 pulp, and in many cases, especially if the lesion is at all extensive, 
 splenectomy (p. 957) should be done. Sheldon (1910), as the result of 
 animal experimentation, advises clamping tbe pedicle of the spleen 
 with rubber-covered forceps; these are loosened in four hours, and 
 if hemorrhage does not recur they are subsequently removed. The 
 splenic wound itself is ignored. This method is more applicable to 
 cases of stab wound than to rupture, since the spleen often is quite 
 disorganized in the latter cases. 
 
 Stab Wounds of the Abdomen. — The symptoms alone are not suffi- 
 ciently characteristic to warrant a diagnosis. They are those of any- 
 abdominal injury: shock, vomiting, pain, and rigidity. The important 
 question to decide in these cases is whether or not the abdominal 
 cavity has been penetrated. Under no circumstances^ should this 
 be left in doubt until the development of peritonitis renders it certain. 
 The question as to which viscus is injured is of quite secondary impor- 
 tance. If protrusion of omentum, prolapse of bowel, or escape of intes- 
 tinal contents renders the fact of penetration certain, no hesitancy 
 need be felt in freely opening the peritoneal cavity. This should be 
 done by a para-median incision. 
 
 If the external wound is small, and there is doubt as to whether 
 the blade actually has entered the peritoneal cavity, cautious explora- 
 tion should be undertaken. The wound should not be explored by 
 sound or finger. It should be stuffed with gauze and the patient 
 should be prepared as for an abdominal operation. The surgeon 
 should then dissect down layer by layer and thus follow the tract 
 of the wound. If difficulty is experienced in tracing a small stab 
 wound, it is best first to lay bare the abdominal aponeurosis (sheath 
 of rectus, aponeurosis of external oblique) over a wide area, and 
 search it for the stab wound. If this cannot be found, and it is known 
 that the blade was very short (that of a pen-knife, for example), and 
 if there are no other symptoms of penetration, the skin incision may 
 now be closed. If, however, it be ascertained that the blade has pene- 
 trated the aponeurosis, the surgeon should next lay bare the trans- 
 versalis fascia and peritoneum, but should not open the latter until 
 he is sure it has been penetrated. I am thus insistent upon this cautious 
 approach to the peritoneal cavity, when the fact of its penetration 
 is in doubt, because it often happens on opening the abdomen widely 
 in these cases that inspection shows no evidence of intra-abdominal 
 lesion, and very extensive search becomes necessary to exclude the 
 
 1 ThL<5 statement, of course, does not refer to wounds received in warfare. 
 These require the same treatment as abdominal gimshot wounds in military life 
 (p. 191). 
 
INJURIES OF THE ABDOMEN 845 
 
 possibility of visceral injury; and it' none be found to exist, and it 
 is shown that the vuhierating weapon itself never had opened the 
 peritoneal cavity, the surgeon will have subjected his patient to a 
 quite unnecessary and by no means trivial operation. If, however, 
 the fact of abdominal jxMietration has been determined by the method 
 just described, the surjivon will be quite justified in his extensive 
 intra-abdominal manipulations, even though no lesion be found more 
 serious than hemorrhage from an omental vein (Deaver and Ashhurst). 
 
 If some of the abdominal contents protrude through a wound 
 their condition will determine their proper treatment. If viable,^ 
 they should be cleansed, any visceral wounds should be repaired, 
 and the viscera should be replaced. For this purpose it may be neces- 
 sary to enlarge the abdominal wound. Omentum which protrudes 
 from an abdominal wound should be excised, as should portions of 
 prolapsed intestine which appear certain to become gangrenous. 
 
 The abdominal structures most often wounded are the following: 
 small intestine, colon, omentum or mesenteries, liver, stomach, and 
 diaphragm. 
 
 After opening the abdomen, the first thing to do is to control hemor- 
 rhage. Each intestinal lesion should be repaired as it is discovered, 
 and should not be put aside with the idea of repairing it later in the 
 operation. Careful search of the entire intestinal tract is necessary, 
 as the lesions often are multiple, and in about one-third of the cases 
 which terminate fatally postmortem examination shows this result 
 to be due to the presence of one or more perforating wounds which 
 were not discovered at operation. The general mortality after opera- 
 tion is about 50 per cent.; it is much higher if no operation is done. 
 When operation is done within the first twenty-four hours the mortality 
 is less than 10 per cent. 
 
 Gunshot Wounds of the Abdomen. — In addition to the general 
 account of these injuries given in Chapter VII, some more particular 
 account of the operative treatment may be gi\en in this place. The 
 probability of penetration is so great that in civil life ever}^ case should 
 be subjected to explorator}' laparotomy at as earh' an hour as possible. 
 The incision should be made close to the median line, in that portion 
 of the abdomen injured. The wound of entrance of the bullet may be 
 disregarded, unless there is hemorrhage through it from a vessel in 
 the abdominal wall; then the wound of entrance should be opened and 
 the bleeding arrested. But it is much better to enter the abdomen 
 through healthy structures, and at the most convenient point, than 
 to make the exploration through the infected bullet tract. The bullet 
 wound, however, should be swabbed out with iodin (3 per cent.) 
 and packed with gauze. 
 
 Gunshot wounds of the intestinal tract usually are perforating, the 
 bullet producing wounds of entrance and exit in each coil of intes- 
 tine which it injures. Sometimes as many as four or six perforations 
 
 ^ See Strangulated Hernia, p. 768. 
 
846 ABDOMINAL SURGERY IN GENERAL 
 
 will be found within a few inches of each other in one coil of bowel. 
 In such cases it may be necessary to excise the segment of gut wounded; 
 but whenever possible suture should be preferred, and even if the 
 repair of the perforations by suture seems to cause some obstruction 
 to the lumen of the gut, I believe it is better to run this risk than to 
 undertake resection. The omentum may be sutured over the damaged 
 area, to reinforce the sutured perforations; or the damaged coil of bowel 
 may be fixed in the wound, to preclude damage from intraperitoneal 
 leakage of intestinal contents, if there is doubt about the sutures 
 holding. If the mesentery is so much damaged as to impair the 
 vitality of a segment of intestine, resection can hardl}^ be avoided. 
 Each lesion should be repaired as it is found ; it is only a waste of time 
 to pass over a perforation thinking to find and repair it at a later 
 stage of the operation. 
 
 Gunshot wounds of the stomach require special mention. The 
 "head-high" (reversed Trendelenburg) posture, with a sand bag 
 under the patient's lower dorsal spine, is a great help in exposing the 
 field of operation. The stomach is best found by identifying first 
 the left lobe of the liver, and passing the fingers from its under surface 
 over the gastro-hepatic omentum on to the anterior wall of the 
 stomach. Usually there is both a wound of entrance and one of exit. 
 The wound first found should be repaired at once. If no other wound 
 is found on the anterior wall, the gastro-colic omentum should be 
 divided, between hemostats, on the colonic side of the gastro-epiploic 
 arteries, and for a distance at least of three inches. The existence of a 
 perforation on the posterior wall usually will be indicated by extrava- 
 sation within the lesser peritoneal cavity. W. Martin (1907) found 
 that among the cases he studied failure to suture the bullet-hole in 
 the posterior gastric wall had not materially influenced the mortality. 
 A perforation should be sutured if found; if inaccessible from the 
 posterior wall of the stomach the surgeon may open the anterior wall 
 of this organ and suture the posterior perforation from inside the 
 stomach. If more room is required to expose a perforation in the 
 cardiac region of the stomach, temporary resection of the costal 
 margin may be adopted; if the line of section is kept in the cartilages 
 (not invading the bony structure of the ribs), the pleural cavity will 
 not be opened (Auvray). Drainage of the lesser peritoneal cavity 
 should be secured by a wick of gauze emerging through the gastro- 
 colic omentum; hemorrhage from this structure, which has been con- 
 trolled during operation by hemostats, is permanently arrested by 
 suture. Drainage through the left loin seldom is required; but some 
 form of drainage of the lesser peritoneal cavity never should be 
 neglected, particularly in cases where the pancreas has been injured. 
 Another drain should be placed anterior to the stomach, and in 
 cases where gastric or intestinal contents have been diffused in the 
 abdomen, the pelvis should be drained also through a suprapubic 
 opening. 
 
 Gunshot wounds of the duodenum are rare, scarcely ever uncompli- 
 
IXJl h'IKS OF THE AHDOMEM 847 
 
 cated l.y <,tluT K'si„ns an.l usually fatal. Proper exposure is difficult 
 an.l It may hv nnpossihle to suture or even to discover a perforation 
 on the retroperitoneal surface. Usually it will be well to drain the 
 suturcl area especially if it is retroperit<.neal. Drainage ahva vs should 
 be employed, preferably throuj^h the loin, if a retroperitoneal perfora- 
 tion IS suspecte.1 but not definitely located, or if one is located in 
 an maccessible p.>s,tion. Ke.section with end-to-end ana.stomosis may 
 be required n many instances it probably will be safer to close 
 both ends of the duodenum, and do gastro-jcjunostomv or duodeno- 
 jejunostomy (Deaver and Ashhurst). 
 
 • r!lf ^?-V''',""'^? ''^}^'' ^'''' "f*^" ^>'^^fi profu.seIy. There usually 
 IS httle difficulty m checking bleeding by suture or tampon, and if 
 hemorrhage is arrested in good time, the immediate prognosis is 
 reasonably good; though secondary complications, such as hepatic 
 or subpiirenic abscess, empyema, or pneumonia, are much to be 
 feared. Ihe general mortality after operation is from 35 to 40 per 
 cent.; in a series of 37 cases uncomplicated bv injuries of other 
 viscera, the mortality was only 16 per cent. (Patel and Loaec, 1912) 
 (runshot wovmds of the .spleen, as in the case of subcutaneous 
 injuries, frequently cause so much disorganization as to require 
 splenectomy. ' 
 
 Gunshot wounds of the pancreas almost alwa^•s are complicated 
 by injuries of surrounding viscera. The best exposure is gained 
 through the gastro-colic omentum. Tamponade is more successful 
 than attempts at suture. Drainage always should be emploved If 
 the injury is undiscovered, death is practicallv certain. ThV death 
 rate after operation is about 43 per cent. (Diehl, 1911) 
 
CHAPTER XXIII. 
 SURGERY OF THE GASTRO-IXTESTIXAL TRACT. 
 
 SURGERY OF THE APPENDIX VERMIFORMIS. 
 
 Appendicitis. — Inflammation of the vermiform appendix of the 
 cecum is the most frequent form of abdominal disease seen by the 
 surgeon. Its s\Tnptoms were described even by authors of classic 
 times; but no one, except perhaps Melier, in 1S27, considered disease 
 of the vermiform process as the chief, if not the sole cause of these 
 symptoms until it was proved, about thirty years ago, by IMatter- 
 stock in Germany that almost aU abscesses in the right iliac fossa 
 were associated with a perforated appendix; and by Fitz in America 
 that in cases of so-called typhlitis (inflammation of the cecum) and 
 in cases of appendicitis the symptoms were identical. The term 
 appendicitis was introduced by Fitz in 1886. 
 
 Pathogenesis. — The anatomy of the appendix predisposes it to 
 inflammation. It is filled with fecal matter charged with bacteria; 
 it contains a long mucous canal which opens by a narrow orifice into 
 the cecum; usually it is more or less kinked or twisted, owing to the 
 shape of its mesentery; and the slightest swelling of its walls at any 
 point may cause complete obliteration of its lumen, converting its 
 distal segment into a closed cavity whose naturally infectious con- 
 tents are thus markedly increased in virulence. In addition to these 
 factors, the appendix possesses a precarious blood-supply : it possesses 
 no collateral circulation; its arteries are "end-arteries;" and the 
 slightest swelling or constriction or kinking of the organ may cut 
 oft' the blood-supply completely, resulting in partial or total necrosis. 
 
 The infection, in the vast majority of cases, is enterogenous; but 
 hematogenous infection sometimes occurs (p. 850). In enterogenous 
 infection the bacteria swarming in the fecal contents of the appendix 
 produce a sub-epithelial reaction, which is known as the primary 
 focus (Frimarinfekt) of Aschoff (1908). This occiu-s in the depths of 
 one of the mucous crypts of the appendix, and consists of a collection 
 of neutrophile leukoc\"tes. The epithelium itself, which overlies the 
 primary focus, may be destroyed very early in the process, its place 
 being taken by a plug of fibrin. Usually a number of these primary 
 foci develop simultaneously. The inflammatory reaction spreads very 
 quickly toward the serous coat of the appendix, and peritonitis may 
 develop before the mucous surface is seriously diseased. In almost 
 every case, the primary infection is due to the streptococcus; but 
 invariably the colon bacillus invades the walls of the organ secondarily, 
 
APPENDICITIS 849 
 
 and soon ovor-fjrows the strrptoromis, so that cultures of the latter 
 are lost. 
 
 If resolution does not occur at this \-ery early staf^e of ajjjjendicitis, 
 these intranuiral foci become confluent, and the condition is known as 
 simple phlegmonous appendicitis. The existence of a primary catarrhal 
 appendicitis, with ulceration as its result, is denied by Aschoff; what 
 was formerly described as catarrhal apjx'ndicitis is now recognized 
 as phle<:;monous (intramural) in nature. This phlegmonous stage is 
 present, with few exceptions, whenever the disease has lasted more 
 than twelve hours. Even should resolution occur at this early stage of 
 the disease, the appendix will not return to its normal state; cicatricial 
 tissue remains, .strictures may form, and the organ is more than ever 
 predisposed to infection. If resolutions does not occur early in the 
 phlegmonous stage of the disease, intramural abscesses develop, 
 miliary in size. These are prone to perforate the serous coat of the 
 a])pen(lix {miliary perforalions), causing jicritonitis without macro- 
 scopic perforation of the appendix. Or they may rupture into the 
 lumen of the appendix, producing ulcers. Ulcerative appendicitis 
 never is the primary stage; it follows the phlegmonous, whether or 
 not this has progressed to the stage of suppuration. In this ulcerative 
 stage the mucous membrane frequently is honorrhagic; but the most 
 serious complications of this stage are (1) ulcerative perforation (macro- 
 scopic), which usually occurs on the anti-mesenteric border of the 
 appendix; and (2) necrosis of the wall of the appendix. This necrosis 
 may be the result of anemia from vascular thrombosis, or it may be 
 due to the direct toxic influence of bacteria on the appendicular wall. 
 In either case secondary invasion of the necrotic area by putrefactive 
 microbes (from the fecal contents of the appendix) leads to gangrene. 
 Separation of the slough formed in this manner produces yet another 
 variety of perforation. 
 
 Every attack of appendicitis passes through all the stages described 
 unless arrested spontaneously or unless the appendix is removed. 
 
 If resolution occurs early in the phlegmonous stage of the disease, 
 and if the appendix suffers a number of such mild attacks (which may 
 be so mild as to pass unnoticed), a condition described as chronic 
 appendicitis may develop.^ This term implies not so much a chronic 
 inflammation, as defined at p. 35, as it does the result of previous 
 inflammatory attacks. The lesions are fibrotic and sclerotic in nature, 
 and are most marked in the distal portion of the appendix, especially 
 behind a stricture. In some cases repeated mild attacks lead to 
 obliteration of the lumen of the organ, through the process of adhesion 
 between its apposed granulating walls. This appendicitis obliterans 
 (Senn, 1894) usually affects only the tip of the organ, but as the patient 
 ages the entire lumen may be obliterated. 
 
 1 This is the teaching of Aschoff, whose studies of the pathology of appendicitis 
 are the most recent and accurate. Other authorities have held that an acute 
 attack seldom occurs except in an appendix already the seat of chronic appendicitis. 
 Both views are harmonized if we admit that chronic appendicitis alway.s begins 
 with a definite attack which is acute pathologically, no matter how mild chnically. 
 54 
 
850 SURGERY OF THE G ASTRO-INTESTINAL TRACT 
 
 Strictures, or actual occlusion of the lumen of the appendix may 
 occur at \arious points. If a stricture only is present, it is usual for 
 a coprolith or fecal concretion to develop behind it (Fig. 837), or 
 between two strictures. If complete occlusion exists the tip of the 
 appendix beyond the occlusion or the segment lying between two 
 occluded points may become the seat of an empyema, during an acute 
 attack; or if the infection dies out a cyst may succeed the empyema. 
 Not infrequently in an acute attack temporary occlusion (from edema 
 or kinking) occurs close to the cecum and the whole appendix is con- 
 verted into an abscess, sac. Fecal concretions found in the a})pendix 
 at operation almost surely are the result of a previous attack of 
 appendicitis; after they are once formed they predispose, by their 
 mechanical action, to further attacks and especially to perforation, 
 which occurs oftenest behind the concretion. Foreign bodies which 
 are rare in the appendix, act in much the same way as do the fecal 
 concretions: they may lie in the lumen of the appendix for years 
 without producing any symptoms. 
 
 Fig. 837. — Gangrenous appendix with fecal concretion near tip. Note thickness 
 of wall«. indicating previous attacks; stricture on proximal side of concretion; and 
 imi)f'ndin{i perforation near tip. Episcopal Hospital. 
 
 Causes. — Appendicitis is commonest between the ages of ten and 
 thirty years, when all infectious disorders are most prevalent. Strep- 
 tococci, especially diplococci, are the bacteria most often directly 
 responsible for an attack of the disease; but why it is that they produce 
 the attack at any given time is a mystery. The great frequency of 
 enterogenous infection has already been noted; and it is probable that 
 stagnation of the contents of the appendix from kinking is the main 
 predisposing cause. Digestive derangements increase the virulence 
 of bacteria in the intestinal canal, or are the result of this increased 
 virulence ; and disordered peristalsis may force fecal matter containing 
 these highly virulent organisms into the appendix. There is no good 
 proof that appendicitis arises as the extension into the appendix of a 
 catarrhal inflammatory process in the cecum. It is probable that intes- 
 tinal parasites found in the appendix (Fig. 838) have no etiological 
 significance. 
 
 In some cases it is possible that infection occurs through the blood- 
 stream (hematogenous). In this connection attention has been called 
 (by Kellynack, Kretz, and others) to the histological resemblance of 
 the appendix to the faucial tonsils, both of them containing much 
 lymphoid tissue; and it has been held that appendicitis is an abdominal 
 angina. But neither the clinical history of the patients, nor the 
 
AI'I'KSDICITIS 851 
 
 liist()l<),<;ic;il cximiinatioii of X\\v disoast'd a])i)(MHlicrs supports the theory 
 of heinatoj^euous infeclion, except in extremely rare instances. 
 
 One attack of appendicitis predisposes to another. Nearly 85 per 
 cent, of oOOO |)aticnts under Deavcr's care bad bad a previous attack. 
 
 Fig. 838.— Acute ai)|)("iulicitis, appendix containiii}; oxyuiis vcnniculaiis. (Xaturu 
 size.) Episcoi>al Hospital. 
 
 Acute Appendicitis. — Symptoms and Clinical Course. — Pain, 
 nausea, and vojuiiing followed by tenderness and rigidity: These are 
 the cardinal symi)toms of acute appendicitis. Usually without pre- 
 vious warning- the patient develops a sudden colicky pain, more or less 
 diffused throughout the abdomen or localized to the umbilical region. 
 This pain is due to the disordered peristaltic action of the appendix 
 in attempts to empty itself against resistance. It is analogous to the 
 pain of biliary, intestinal, or renal colic; like them it excites nausea 
 and vomiting. The ^•omiting is reflex, and suffices only to empty the 
 stomach. It is not repeated unless peritonitis develops, when it 
 assumes the type already described at p. 806. This primary nausea 
 and vomiting follows and does not precede the initial pain of appen- 
 dicitis; to this rule there are very few exceptions. At this time there 
 is no special tenderness in the abdomen; indeed, as in intestinal colic, 
 pressure "may relieve the pain. But usually within twelve hours the 
 character of the pain changes; it is no longer diffuse and colicky, but 
 becomes localized to the right iliac region, where the diseased appendix 
 is found. The pain is now burning, constant, and intense. Simul- 
 taneously with this localization of the pain to the right iliac fossa 
 there develop both tenderness and rigidity, which also are confined 
 to the region of the appendix. Palpation now reveals a normal 
 abdomen elsewhere, but over the right iliac fossa the muscles (par- 
 ticularly the right rectus) are rigid, and tenderness is so marked that 
 even slight pressure causes extreme pain. This localized rigidity is 
 the most important single symptom of appendicitis. Roughly speaking, 
 all these symptoms of appendicitis are localized around McBumey's 
 point, which was described by its author in 1891 as a point from one 
 and a half to two inches distant from the anterior superior spine of 
 the right ilium on a line drawn between this spine and the umbilicus. 
 
 When this stage of the disease has been reached it is possible in all 
 but the most exceptional cases to make an accurate diagnosis of appen- 
 dicitis. The condition is clinically one of localized peritonitis, as 
 described at p. 805, and that this is the pathological state is evident 
 from the account of the pathogenesis of appendicitis already given. 
 
852 SURGERY OF THE GASTRO-INTESTINAL TRACT 
 
 Appendicitis is localized peritonitis; all the signs of this condition are 
 present : tenderness and rigidity, arrest of peristalsis in the immediate 
 vicinity of the lesion, local tympany from paresis and distention of 
 the ileo-cecal coil of the intestinal canal; and persistent constipation. 
 The development of complications should not be awaited before 
 making an accurate diagnosis. 
 
 In a small proportion of cases the attack does not begin with acute 
 pain, but with a gradually increasing discomfort in the neighborhood 
 of the appendix; and in such cases, the physical signs of appendicitis 
 often develop without any nausea or vomiting. Hence it is, that in 
 appendicitis as in all other acute abdominal lesions when the history 
 of the case is atypical, it is safer to rely on the physical examination 
 than on the history, in reaching a diagnosis. 
 
 No mention has been made hitherto of the temperature, pulse, or 
 leukocytosis, in connection with appendicitis. They are of_ quite 
 secondary importance. Usually the temperature is slightly elevated 
 from the first, and the pulse quickened, as in all febrile states. There 
 also is leukocytosis in most cases, the white blood cells numbering 
 anywhere from 10,000 to 40,000. The white-blood count is of more 
 value in prognosis (p. 859) than in diagnosis. 
 
 When the stage of localized symptoms described above has been 
 reached, the disease pursues either one of two courses: It subsides, 
 or complications develop. In the former case the pain gradually 
 lessens; the tenderness changes to mere "soreness," rigidity disappears, 
 flatus is passed normally, the temperature curve reaches the normal, 
 and the leukocytosis gradually subsides. The course of such an 
 attack lasts on the average from three days to a week. If the attack 
 does not subside, complications develop; they are frequent and almost 
 countless. Among the more important are perforation and gangrene 
 of the appendix, and abscess formation or diffuse peritonitis with 
 all its dire consequences. The symptoms, diagnosis, and treatment 
 of these complications are considered at p. 857. 
 
 Diagnosis. — The diagnosis of appendicitis usually is easy. It is 
 the most frequent of all acute abdominal diseases, and should be ever 
 in the surgeon's mind. In intestinal colic the pain is general and does 
 not become localized to the region of the appendix; pressure relieves 
 it; nausea and vomiting are by no means constant, and often precede 
 the onset of the pain; active peristalsis is audible; and diarrhea is the 
 usual outcome. At no period of the attack is there muscular rigidity. 
 Fever is unusual. Leukocytosis is absent. In biliary colic the pain 
 is situated in the right hypochondrium and often radiates to the 
 right shoulder. A history of many previous attacks often is obtainable, 
 and jaundice may have been present at some time. Tenderness and 
 rigidity if present are confined to the gall-bladder area. If the patient 
 is past forty years of age the attack probably is biliary, not appen- 
 dicular. In acute cholecystitis the symptoms somewhat resemble those 
 of biliary colic. Tenderness and rigidity are constant, but are con- 
 fined to the upper right abdominal quadrant, unless the gall-bladder 
 
M'i'i<:si)i('iTis 853 
 
 IS (lisplaccd. TIu« clmnictcrislics by vvliicli ;iii enlarged Kull-hladdcr is 
 nc.un.z,-,! an- stated at p. <)L'(). Jn renal colic from disease of the 
 right kidney, the symptoms may elosely simulate those of ai)peii- 
 dieitis, particularly when a ealcuhis is lod^vd j,, the ureter Yet tlie 
 ra(hatiou of tlie pain, the urinary HikHuks, aii<l tiie absenee of gastro- 
 iiitestinal symptoms suffice lu most cases to make the diagnosis clear 
 Skiagrapliy is a vahiabie aid. In acute salpinqiiis, especially affecting 
 tlie right tube, the peritoneal symptoms are confined to \he pelvis 
 uiK gastro-mtestmal symptoms are absent. Tenderness is too low 
 and too near the median line, for appendicitis; it is not at McBurnev's 
 pomt, but about over the middle of Poupart's ligament. Vaginal 
 examination confirms the diagnosis. Some cases of typhoid fever 
 begin with rather acute abdominal i)ain, and this mav be accompanied 
 by nausea and vomiting. I'sually, however, strici inquirv reveals 
 that the actual onset of the disease occurred several da^'s previously 
 with niahuse, headache, feverishness, etc. The tem]3erature is too 
 high ( ().] l^ or more) and the pulse too slow (]()() or lower) for 
 appendicitis; and there is leukopenia not leukocytosis. 
 
 In none of the affections mentioned, nor in any of the score or more 
 other diseases which may be exceptionally confused with appendicitis, 
 is the clinical history typical of the latter: midden pain, first diffuse 
 then settling to the right iliac ioH^a; followed bv vomiting; and the 
 extremely important localized tenderness and rigidity. 
 
 Prognosis.— The appendix is the fons et origo mall, and if it is 
 removed before complications develop, the prognosis is brilliant 
 1 he mortality of operation at this stage of the disease is so low that 
 hundreds and hundreds of such simple cases are cured without a death 
 Once m se^■eral hundred operations it may happen that a patient dies 
 of pneumonia or some other unforeseen complication; but this minimal 
 risk stands in no sort of relation with the risk run bv delaying operation 
 to determine whether or not complications are about to develop. 
 As a matter of fact, even under the most approved non-operative treat- 
 ment complications develop in at least 10 per cent, of cases. It was 
 justifiable to delay operation only in the thiNs before the develop- 
 ment of aseptic surgery; until that time the onlv form of intra-abdomi- 
 nal disease successfully amenable to surgical treatment was localized 
 suijpuration. It was then and it is now absolutely impossible to 
 contro the course of the disease in the appendix by anv means known 
 to medical science.^ Unless the appendix is removed the patient is 
 left to the unaided efforts of nature. Never should the surgeon call 
 for aid from beneficent Nature until he has exhausted his own 
 resources. Apollo would not help the teamster until the latter had 
 whipped up his horses and put his own shoulder to the wheel. The 
 mere diagnosis of appendicitis should be an indication for immediate 
 operation. I am conceited enough to believe that I can recognize, 
 as well as anyone else, the occurrence of perforation or suppuration 
 
 of \his disiS?'"^ ""^ "^'^^^^ ^"^ '^^ «ppenrfe, not of the peritoneal complications 
 
854 
 
 SURGERY OF THE GASTRO-INTESTINAL TRACT 
 
 in appendicitis, l)ut I frankly confess my ntter ina})ility to feel sure 
 one hour that neither of these events will occur durinji; the next, so 
 long as an acutely inflamed appendix remains within a patient's belly. 
 It is possible to argue on probabilities, and to defer ojjcration in cases 
 that appear mild; but sooner or later the surgeon will encounter a 
 case which will make him regret his procrastination, and will C()n\ince 
 him that he has lost the life of his patient through over-conhdence 
 in his own powers of prognostication. Even if life be not lost, it 
 will be surely jeopardized by the development of peritonitis, localized 
 or diffused, with the possibility of its lethal sequels, such as gangrene 
 of the bow^l, intestinal obstruction, pylephlebitis, etc. It is strange 
 that well-meaning physicians, and even some apparently intelligent 
 surgeons will delay operation, trusting to be warned of impending 
 danger by wTll-defined symptoms in time to employ an operation, 
 when the best time for operation is before alarming symptoms arise. 
 Only in the very aged, or in those with extremely serious visceral lesions 
 (cardiac or renal) is delay justifiable. 
 
 Treatment. — The abdomen should be shaved and cleansed and 
 the bladder emptied (by catheter if necessary) as before any abdominal 
 operation. No other preparation is required, but in many cases it is 
 well to empty the lower bow^el by enema. 
 
 Operation. — I prefer, and habitually employ, the transverse incision 
 of G. G. Davis. Other incisions for appendectomy have been described 
 
 in Chapter XXII. This transverse 
 incision is so planned that its centre 
 lies over the right semilunar line, at 
 the le\el of the anterior superior 
 spine of the ilium. In simple acute 
 cases the incision is from one and a 
 half to two inches long (Fig. 839). 
 The skin and subcutaneous tissues 
 are divided, exposing the aponeurosis 
 of the external oblique. This, and 
 the anterior sheath of the rectus are 
 incised in the same transverse direc- 
 tion throughout the inner half of 
 the wound. The muscle fibres of the 
 rectus are thus exposed, and are to 
 be retracted toward the middle line. 
 In this way the posterior sheath of 
 the rectus and the trans^'ersalis 
 fascia are exposed. The peritoneal 
 cavity is next opened in the usual way, in a transverse direction. The 
 left forefinger is then inserted into the peritoneal cavity, and hooks 
 up the abdominal wall on the outer side of the opening already made. 
 With blunt scissors the operator then splits the internal oblique and 
 transversalis muscles outward in the direction of their fibres (which 
 here run directly trans\'ersely), thus passing ])arallel to the motor 
 
 Fig. 839. — Transverse incision for 
 appendectomy ; two weeks after opera- 
 tion. Episcopal Hospital. 
 
Ari'ESDicrns 855 
 
 nerves of tlie abdominal wall. 'I'lu- transversalis fascia and perito- 
 neum are then eut in the same direction, throu<,diout the whole extent 
 of the wound. If more room is needed toward the median line, the 
 anterior and posterior sheaths of the rectus may be incised as far as 
 the linea alba, but the muscle itself need not be cut, as it can be 
 drawn far to the left with a retractor. If more room is needed to the 
 outer side, the oblitiue and transversalis muscles may be cut as far 
 as the iliac spine, or further if necessary, without any damage to the 
 abdominal nerves. Some branches of the deep circumflex iliac artery 
 may be cut if the wound is extended outward, but the only muscular 
 fibres which will be cut across are those of the external ol)li(iue; but in 
 mo.st cases the inc'sion involves only the aponeurosis of this muscle, 
 not its muscular fibres. 
 
 Locating the Appendix. — First Method. — Place two fingers of the 
 left hand inside the abdominal wound and follow the parietal 
 peritoneum of the anterior alxlominal wall downward to Poupart's 
 ligament; then carry the fingers upward along the brim of the pelvis 
 (recognized by the pulsations of the external iliac artery) until they 
 are arrested. The structure which arrests them will be the mesentery 
 of the ileo-cecal region. Usually the appendix can be recognized in 
 this position by the sense of touch, and if not adherent can be drawn 
 out of the abdominal wound betw^een the index and middle fingers. 
 Second method: Pass the fingers of the left hand along the parietal 
 peritoneum on the outer side of the wound, and let them follow the 
 parietal peritoneum inw^ard across the iliac fossa. The structure 
 which arrests them will be the cecum or ascending colon with its 
 mesentery. Draw the cecum into the wound and trace its longitu- 
 dinal bands downward until they converge at the base of the appendix 
 which is then delivered. Third method: This is less brilliant than 
 those just mentioned, but it is the surest method of all. Pack all the 
 abdominal contents to the patient's left, by inserting gauze sponges. 
 When all the movable structures have been thus carried away from 
 the seat of operation, only the immovable will remain. This is the 
 cecum, attached to the posterior abdominal wall by its short mesen- 
 tery. When the cecum is thus found, draw it out of the wound, and 
 trace it downward until the appendix is delivered. 
 
 Removal of the Appendix. — (1) Pass an aneurysm needle, carrying 
 No. 1 chromic catgut, through the meso-appendix close to the base of 
 the appendix and tie this ligature around the free border of the meso- 
 appendix as far away from the appendix as possible. If the meso- 
 appendix is very thick or long, it is safer to tie it in two or three 
 sections. (2) Cut the meso-appendix as close to the appendix as pos- 
 sible, thus leaving enough tissue beyond the ligature to prevent its 
 slipping (Fig. 841). (3) Clamp the appendix at its juncture with the 
 cecum, and clamp it again about a centimeter distant. Remove the 
 first clamp and ligate the base of the appendix in the groove crushed 
 by the clamp, using No. 1 cliromic catgut (Fig. 842). (4) Cut the 
 appendix between the ligature and the distal clamp. The stump of 
 
856 
 
 SURGERY OF THE GASTRO-INTESTINAL TRACT 
 
 the appendix may he touched with phenol and with alcohol, but I 
 regard this as an unnecessary refinement of technique. (5) Insert 
 
 Fig. 840. — The blood-sui)i)Iy of the cefuni and appendix. 
 
 Fig. 841. — Appendectomy: the nieso- Fig. 842. — Appendectomy: the base of 
 
 appendix has been tied close to the base tlie appendix has been ligated in the 
 
 of the cecum, and then divided close to groove made bv clamping a hemostat; a 
 
 the appendix. second hemostat is left in place. 
 
 a purse-string suture of linen thread in the cecum about 2 cm. away 
 from the stump of the appendix (Fig. S43) ; then cut the ends of the 
 appendicular ligature short, and as the stump of the appendix is 
 
COMPLICATIOXS OF APPENDJCiriS 
 
 S57 
 
 jK'ritoiieiim and pos- 
 slieatli of tlic rectus 
 
 
 Fi(!. 843. — Appendectomy: the ap- 
 pendix has been cut off, and a purse- 
 string suture has been inserted in the 
 cecum. 
 
 pushed inward, tie tlie purse-string suture, thus completely burying 
 the stumj). (()) Look at the meso-ap|)endix to make sure that the 
 lif^ature has not slii)pe(l, and then cut the lifjature short. (7) Finally, 
 close tlie abdominal wound, suturing (//) the 
 terior sheath of the rectus; (6) the anterior 
 and the internal oblique and trans- 
 ver.salis muscles; (c) the external 
 oblique aponeurosis. Each layer is 
 sutured with a continuous suture 
 of chromic catgut. Tie any bleed- 
 ing points in the superficial fascia; 
 and then close the skin wound 
 with interrupted sutures of silkworm 
 gut. 
 
 In vnroniplicdted cases of appen- 
 dicitis no drainage is required, and 
 no special after-treatment is to 
 be pursued. The patient may have 
 hot water, in amounts of a half 
 ounce (15 c.c.) or less, every fifteen to 
 
 thirty minutes, by mouth, after twelve hours. Liquid diet is begun 
 after twenty-four hours and is continued for three days, when soft 
 diet is allowed. Full diet may be given after the tenth day, wdien the 
 wound is first dressed and the skin sutures removed. If the bowels 
 do not move spontaneously by the third or fourth day, an enema should 
 be given, and only when this proves ineft'ectual is a purge required. 
 I prefer to keep my patients in bed at least two weeks, but many 
 surgeons allow them to be up in a week or ten days. 
 
 If operation cannot be done, then, so soon as a diagnosis is made, 
 treatment should be instituted as already advised for cases of difi^use 
 peritonitis (p. 810). By adherence to the strictest code of the Ochsner 
 treatment, it usually will be possible to prevent the development of 
 widespread peritonitis; but even under the best circumstances, an 
 abscess will form or some other complication develop in about 10 
 per cent, of cases. Nothing is so surely productive of complications as 
 the adminisiraiion of purgaiives. 
 
 Complications of Appendicitis. — From a clinical point of ^•iew the most 
 frecpient complications of appendicitis are abscess, diffuse peritonitis, 
 and gangrene of the appendix. There is no greater fallacy than to 
 suppose, as is done by many physicians, that neither abscess nor 
 peritonitis can occur unless there is a macroscopical perforation of 
 the appendix. Macroscopical perforations are comparatively rare, 
 and even when present usually are of secondary importance to 
 the abscess or the diffuse peritonitis which dominates the clinical 
 picture. 
 
 Among the complicated cases of appendicitis under my own care, 
 the following lesions ha\e been the cause of the predominating 
 symptoms : 
 
858 
 
 SURGERY OF THE GASTRO-INTESTINAL TRACT 
 
 Primary abscess in 19.1 percent. 
 
 Residual abscess 11.2 " 
 
 Gangrene 24.7 " 
 
 Diffuse peritonitis .... 44.9 " 
 
 Mortality. . 
 
 0.0 per cent. 
 20.0 
 
 13.6 " 
 17.5 
 
 The general mortality for the ientire series of complicated cases of 
 appendicitis is I'A.o per cent. Not one of these patients would have 
 
 died if operation had been done 
 within twenty-four hours of the 
 onset of the disease, and even 
 those patients among the com- 
 plicated cases who recovered 
 would have been saved the 
 discomforts and prolonged con- 
 valescence attending a drained 
 wound. 
 
 Primary Appendicular Ab- 
 scess. — This is the least dan- 
 gerous of the complications of 
 appendicitis. The reaction of 
 the peritoneum to the appen- 
 dicular infection is adequate, 
 and the infection remains local- 
 ized to the immediate neigh- 
 borhood of the appendix. The 
 most frequent site of such ab- 
 scess is in the right iliac fossa\ 
 Other frequent sites are the 
 pelvis and the right flank or 
 loin, depending upon the posi- 
 tion of the appendix (Fig. 844). An abscess on the median side of 
 the cecum, or among the coils of small intestines is unusual; one 
 
 Fig. 844. — Usual sites of appendicular 
 abscess: 1, in the right iliac fossa; 2, in 
 the pelvis; 3, in the right kidney pouch. 
 
 v:!-- 
 
 FiG. 845. — Perforated appendix, forming part of an abscess wall; perforation 
 into adhesions. Episcopal Hospital. 
 
 between- the layers of the mesentery of the ileum, or elsewhere in 
 the retroperitoneal tissues, is very rare. In most cases the wall of the 
 abscess is formed by the parietal peritoneum of the iliac fossa, pelvis 
 
A PPENDICULA R A BSCESS 
 
 859 
 
 or flank, on one side; l)y tlu- cociiiii, adherent omentum or anterior 
 abdominal wall, in front ; while its medial wall is formed by omentum 
 or eoils of small intestine. The appendix usually forms a part of the 
 abseess wall at some point (Fig. S4')), but may lie entirely within the 
 abscess cavity. It may or may not present a maeroscopical perforation. 
 St/niptoms. — So long as the pus is under tension there are the usual 
 symptoms of toxic absorption, such as elevation of temperature, 
 increase in the pulse rate, and leukocytosis. If a differential count 
 shows more than DO per cent, of the white-l)lood cells are i)olymicleated, 
 it usually indicates the presence of pus provided there is hyperleuko- 
 cytosis. A high white count, with a low polynuclear percentage, 
 indicates ])()or resistance on the j)art of the j^atient. If leukocytosis 
 is not marked and the polynuclear percentage is low, it indicates 
 either that the abscess is completely localized and that no absorption 
 is occurring, or that the patient is overwhelmed by the infection. 
 The clinical picture must be relied upon to distinguish between these 
 two states. When only a small abscess has formed, and has become 
 well localized so that no absorption is occurring, a careless observer 
 may be led to think that the patient has entirely recovered. In such 
 cases secondary leakage of the abscess may occur, resulting in diffuse 
 peritonitis. 
 
 Fig. 846. — Large appendicular abscess two weeks after onset. X on anterior superior 
 spine of ilium. Outlines of abscess indicated by a drainage tube. Episcopal Hospital. 
 
 The physical signs present depend upon the duration of the abscess 
 and upon its size. Soon after the formation of an abscess, the rigidity 
 and tenderness so characteristic of appendicitis in its earlier stages 
 may persist to such a degree that recognition of a mass by palpation 
 may be impossible. But by percussion it usually is possible to demon- 
 strate an area of dulness in the right iliac fossa. Such dulness, however, 
 frequently is due to a mass of adherent omentum; and it is not safe 
 to assume that a mass, even if distinct and papable, contains much 
 pus. The quantity of pus may vary from a few- drops up to a pint 
 or more. Seldom does the abscess contain more than 10 to 15 c.c. 
 of pus. Palpation through the rectum may discover a bulging, tender 
 mass in the rectovesical pouch, or in women behind the uterus Rectal 
 touch is particularly valuable in small children, for in them a large 
 pelvic abscess may pass unnoticed if this examination is neglected. 
 
S60 SURGERY OF THE GASTRO-INTESTINAL TRACT 
 
 If the appendicular abscess has been in existence for several days, it 
 usually is possible to define its outlines by palpation, and in cases of 
 very long duration the abscess may be visible at a glance as a large 
 rounded tumor (Fig. 846). 
 
 Residual Appendicular Abscess. — This is one which forms after 
 the subsidence of diffuse peritonitis caused by appendicitis. It has 
 also been termed a post-Ochsner abscess, because localization of the 
 infection has been brought about by adherence to the Ochsner treat- 
 ment (p. 811). The pathogenesis, symptomatology, and treatment 
 of these conditions have been discussed in Chapter XXII. 
 
 Treatment of Appendicular Abscess. — An appendicular abscess should 
 be evacuated, and unless the patient is very gravely ill the appendix 
 should be removed at the same operation. But if it is very difficult 
 to find the appendLx, or if it is extremely adherent, it need not be 
 removed. Deaver says it is better to have a live patient with his 
 appendix still in, than a dead patient without one. Operation for 
 abscess should be undertaken as soon as possible after the diagnosis 
 is made. There is nothing to be gained by delay, and in many cases, 
 especially of residual abscess, there is danger that the adhesions 
 limiting the abscess may give away, and that diffuse peritonitis may 
 follow the leakage of pus. 
 
 It is the teaching of Deaver, and many surgeons are in accord with 
 him, that it is best always to open the appendicular abscess at the 
 place where it comes in contact with the parietal peritoneum. To my 
 mind there are serious objections to this teaching: (1) in the vast 
 majority of cases there is no way of telling beforehand whether or not 
 the abscess is in direct contact with the abdominal wall, and as a 
 matter of fact in a great many cases no such direct contact exists; 
 (2) in cutting down upon the point where the abscess is supposed to 
 be in contact with the abdominal wall, one cannot be sure that he will 
 not extend his incision too far in one direction or the other and so 
 trespass upon uninfected peritoneum at the same moment that he 
 gives exit to the pus, thus running the grave risk of spreading infection 
 within the peritoneum; (3) in an endeavor to prevent this error in tech- 
 nique it is necessary to make a funnel-shaped wound in the abdominal 
 wall — very large in its superficial part and very small in the depths; 
 the surgeon has to work in a confined space at the bottom of a deep 
 wound; often the appendix cannot be found, and a second operation 
 is necessary to remove it; and in any event the large wound (made 
 fortuitously according to the site of the abscess, and not with respect 
 to the anatomy of the abdominal wall) must be left open almost in 
 its whole extent, and post-operative hernia is the rule; (4) last, but by 
 no means least, in e\acuating an abscess in this way the surgeon cannot 
 be sure that he has not ruptured the abscess wall on the opposite side — 
 that toward the general peritoneal cavity — thus causing leakage of 
 pus into uninfected areas. Only when the abscess is almost ready to 
 burst through the abdominal wall, or rarely through the rectum, and 
 the patient is gravely ill, am I in the habit of incising directly into the 
 
GANGRENOLS A I'l'ES 1)1(1 TIS 
 
 cSOl 
 
 ahscfss cavity. In such cases, wliich arc mostly residual abscesses, 
 1 make no attempt to remove the aj)pcii(lix at the first operation, 
 which need consume only about five minutes and may be done imdcr 
 local anesthesia or under nitrous oxide. 
 
 In the ordinary cases of appendicular al)scess I believe, with Mnri)hy, 
 that it is nnicli safer first of all to open the iiealthy peritoneal cavity 
 on the median or ui)per side of the abscess mass, and to isolate the 
 entire diseased area b}' gauze 
 packs. Then one may extend 
 the incision to as great a length 
 as seems desirable (Fig. N47) ; 
 and, after evacuating the ab- 
 scess at leisure and with perfect 
 control of the infective material, 
 may complete the ojjcration by 
 removal of the appendix, and 
 may close the greater part of 
 the abdominal wound, leaving 
 only sufficient space unsutured 
 for the emergence of the drains. 
 With such treatment hernia is 
 a very rare sequel, and no sec- 
 ondary operation is required. 
 
 In all operations for appendic- 
 ular abscess the surgeon should 
 make sure that no pelvic collec- 
 tion of pus is overlooked. This 
 is determined by passing a glass tube, along the fingers as a guide, to the 
 bottom of the pelvis; through the lumen of the glass tube a rubber tube 
 is then inserted to the floor of the pelvis, and by means of a syringe 
 attached to its outer end suction is exerted, and any fluid in the pelvis 
 will be drawn into the syringe. If the abscess occupies the iliac fossa 
 or loin, and no pus is found in the pelvis when it is explored as just 
 indicated, it will be safe usually to be content with drainage extending 
 only to the base of the appendix and the site of the abscess cavity. In 
 cases where pus has been found in the pelvis, or in other cases if there 
 is any uncertainty as to the efficiency of the drainage, it is proper to 
 drain the pelvis also. For this purpose a rubber tube suffices, and acts 
 as a better drain than does a-wick of gauze. The drain should emerge 
 at the outer angle of the transverse incision, or at the lower angle of 
 a longitudinal wound. The drain should not be removed for at least 
 four days, and it is better then to shorten it by degrees. Too early 
 removal of the drainage frequently leads to the damming up of pus 
 and the formation of a residual abscess. Though such collections 
 usually can be opened by inserting a finger into the wound, without a 
 general anesthetic, sometimes formal operation is necessary. 
 
 Gaxgrexous Appendicitis. — Though an appendix associated with 
 an abscess or with diffuse peritonitis frequently is necrotic wholly 
 
 Fig. 847. — \'ery large transverse incision 
 in a cas2 of appendicular abscess, drained 
 from its outer end. Two months after opera- 
 tion. Episcopal Hospital. 
 
862 
 
 SURGERY OF THE G ASTRO-INTESTINAL TRACT 
 
 or in part, there is a clinical distinction between such cases and those 
 classed as gangrenous appendicitis. In the latter class, necrosis of the 
 appendix occurs with such rapidity, usually as the result of vascular 
 thrombosis, that no adequate peritoneal reaction develops, and the 
 necrotic organ lies free from limiting adhesions or protecting omentum 
 in an almost normal abdomen. Unless such an appendix is removed 
 promptly, it will separate as a slough from the cecum and fecal 
 extravasation will cause very severe septic (toxic) peritonitis, often 
 costing the patient his life. 
 
 There are no certain syviytoms by which the occurrence of gangrene 
 may be recognized; but sudden cessation of pain, especially if extreme 
 tenderness persists, should make one suspect the occurrence of gan- 
 grene. The fact that gangrene has occurred, thus checking absorption 
 of toxins, may also explain rather abrupt disappearance (unfortunately 
 only temporary) of systemic symptoms of infection. 
 
 The only efficient treatment is immediate removal of the appendix. 
 It is wise to drain the wound in every case. 
 
 Diffuse Peritonitis. — The pathogenesis, symptomatology, and 
 indications for operation have been discussed at p. 806. In cases 
 
 deemed suitable for operation, 
 the surgeon must aim to make 
 the operation as short as possi- 
 ble (Fig. 848). After opening 
 the peritoneum, the appendix is 
 sought, and if readily found is 
 brought into the wound and re- 
 moved. Then a glass drainage 
 tube is passed to the bottom of 
 the pelvis, and any fluid which 
 has collected there is removed 
 by suction as described under 
 the treatment of pelvic abscess 
 (p. 861). If the head of the 
 operating table is raised after 
 evacuating the pelvis, the fluid 
 which lay in the patient's flanks 
 will trickle over the brim of 
 the pelvis and may be removed thence by suction. A gauze wick is 
 carried down to the pelvis behind the glass tube, and both the glass 
 tube and the gauze wick are allowed to remain for drainage. The 
 patient is returned to bed in the head high position, and the usual 
 treatment for peritonitis (p. 811) is continued. The glass tube should 
 be exhausted once or twice daily, and at each dressing should be rotated 
 slightly so as to prevent its fixation by adhesions. When the discharge 
 ceases to be purulent, usually about the third or fourth day, the glass 
 tube should be substituted by one of rubber. The rubber tube should 
 be inserted as far as the floor of the pelvis through the lumen of the 
 glass tube, which is then withdrawn over it ; if the glass tube is with- 
 
 "^^ 
 
 Fig. 848. — Small right rectus incision, in 
 a case of diffuse peritonitis from appendicitis. 
 Episcopal Hospital. 
 
CHRONIC APPENDICITIS 863 
 
 drawn brt'ort' the ruhher tube is in place, the drain tract will collapse 
 and it will be inij)()ssible to insert the rnbber tube. The ^auze wick 
 is rcnio\'e(l from the fourth to the tenth day, and the rubl)er tube 
 is f:;radually shortened, allowinj^ the sinus to heal by {granulation. 
 
 K the appendix is not removed at the first operation, the patient 
 should be strongly urj^ed to have this done so soon as convalescence 
 is coni[>lete. The freciuency of second attacks of a])pendicitis is j^reat, 
 and they are attended by all the dangers of the first. Even should 
 no such acute attacks occur, the presence of the diseased organ and of 
 the adhesions which surround it often seriously impairs the patient's 
 comfort and may render him a semi-invalid; moreover, the appendix 
 may undergo malignant change. 
 
 Chronic Appendicitis. — The pathogenesis of this condition was dis- 
 cussed at p. N41). The ftympioms are many and various. Pain is the 
 most constant symptom and is one without which the diagnosis cannot 
 be made accurately. In most cases the pain is localized to the region 
 affected, but it may be referred through the pull of adhesions to 
 various parts of the abdomen. Gastric dyspepsia is frequent, and may 
 be the predominant symptom. The stomach, as W. J. ^Nlayo points 
 out, is the mouth-piece of the gastro-intestinal tract. Disorders 
 anywhere in this tract are constantly calling attention to their pres- 
 ence through disorders of the stomach. This is true, of course, espe- 
 cially of gastric and duodenal lesions; but it is equally true of gall- 
 stones and of clironic appendicitis, as well perhaps as of other less 
 frequent lesions. The characteristics of the tlyspepsia due to chronic 
 appendicitis are sufficiently distinct to enable a diagnosis to be made 
 in most cases. The gastric symptoms occur with no regularity as 
 regards ingestion of food, nor is relief obtained by eating. Indeed, 
 eating usually aggravates the indigestion, but with no constancy or 
 regularity. The patient complains of general abdominal pain, mostly 
 below tliQ umbilicus. The patient usually is about thirty years of 
 age. Patients past thirty-fi\e years much more often suffer from 
 dyspepsia due to gall-stones, and those past forty years from that 
 due to gastric ulcer or its sequels. Apart from the symptoms of 
 chronic appendicitis, a good deal of reliance should be placed on the 
 history of the case, and particularly on the physical examination. 
 Usually there will have been one or two attacks of abdominal pain 
 or distress sufficiently acute to have laid the patient up for a day or 
 so, even if not so acute as to have been recognized at the time as 
 attacks of appendicitis. Even when such a history is lacking, deep 
 palpation of the abdomen over the right iliac fossa almost invariably 
 detects marked localized tenderness even when none is complained of 
 by the patient. 
 
 Treatment. — The treatment of the disease consists in removal 
 of the appendix. Often this contains a fecal concretion, and evi- 
 dences may be found of past inflammation within the appendix 
 (strictures, obliteration of its tip), or without it (peritoneal adhesions, 
 kinks, etc.). 
 
864 SURGERY OF THE GASTRO-INTESTINAL TRACT 
 
 Primary Carcinoma of the Appendix is found in about 1 per cent, of 
 cases wliicli come to operation or necropsy. Without microscopical 
 examination tlie lesion usually is overlooked. It causes no symptoms 
 which suffice to distinguish it from clironic appendicitis, with which 
 it often is associated. Its frequency is an argument for the removal 
 of the appendix as an incident in the course of other abdominal 
 operations. 
 
 Tuberculosis of the Appendix is scarcely less frequent than carci- 
 noma. If any symptoms are produced the\' are indistinguishable from 
 those of chronic appendicitis, except when the tuberculous infection 
 has spread so far as to give rise to the clinical picture of tuberculosis 
 of the peritoneum (p. 815). The appendix should be removed unless 
 the disease is so widespread as to make this unusually difficult. 
 
 Intussusception of the Appendix has been recorded in a few cases. 
 The symptoms are those of acute appendicitis and the treatment is the 
 same. 
 
 SURGERY OF THE STOMACH AND DUODENUM. 
 
 Gastric and Duodenal Ulcer. — It is probable that these ulcers, as 
 well as others in the gastro-intestinal tract, are toxemic in origin. 
 In practically all toxemias there are gastro-intestinal ulcers, and in 
 practically all cases of gastro-intestinal ulceration there is present 
 some form of toxemia (Dieulafoy, Gandy, 1899). The toxemia is of 
 infectious origin, and the infection may arise in a clironically inflamed 
 appendix, in the biliary tract, or in some other situation which is 
 readily overlooked. Oral sepsis usually is present, and no doubt 
 has etiological relation; constant swallowing of pathogenic microbes 
 impairs the vitality of the stomach, and its acid secretions render 
 it more vulnerable, ^lechanical indigestion, from rapid eating 
 ("bolting" unmasticated food), is another important cause. 
 
 The earliest stage in these gastro-intestinal lesions is ecchymosis; 
 then follow hemorrhagic infarct, slough, and hemorrhagic erosion; 
 next is developed the "exulceratio simplex" of Dieulafoy; then comes 
 the true ulceration with hemorrhagic borders; and then the final 
 stages, perforation, chronic ulcer with thickened border and little tendency 
 to heal, or a cicatrix. These local eflfects probably are due to the 
 action of hemorrhagins, which erode the endothelial lining of the 
 bloodvessels, and of mucolysins, which destroy the gastric mucosa. 
 Ecchymosis, the first stage, is produced by hemorrhagins alone; when 
 mucolysins also act an erosion is produced, and in time a fully 
 developed ulcer will be formed, unless anti-bodies are formed by the 
 organism to hold these cytolysins in check (Hort, 1908). These 
 ulcers are not formed alone in the stomach and duodenum though 
 they are most frequent here. Other similar lesions, not so apt to 
 produce symptoms, may exist in the jejunum or ileum or large intes- 
 tine, but they are comparatively rare. In the mucous membrane of 
 the stomach there are small collections of lymphoid tissue, and these 
 
GASTRIC AM) DUODICNAL ULCER 865 
 
 arc in jfrcatcst iiuiuIht al()ii<f the lesser curNatun' and in the pre- 
 pyloric rcfijion. It seems not ini])rol)al)le (hat inflainniation of these 
 structures, occurrinj;- in general infections, may ha\-e an etiological 
 relation to gastric and pyloric ulcer. 
 
 \\\ ulcer in the stomach or duodenum, when once formed, is diffi- 
 cult to heal, partly owin*:; to trauma from infj;csted food, and to want 
 of rest due to constant i)eristalsis, hut larj^cly ()\vin<i; to chemical 
 chanu'cs in the gastric secretions, produciuj:; Iti/prrclilorln/drKt.'^ 
 
 Duodenal ulcers are more frequent than <;astric (as ;> to 2), and of 
 gastric ulcers those near the pylorus and along the lesser curvature of 
 the stomach are much the most frequent. 
 
 At first "acute," "round," or "open" in type, the ulcer through 
 long duration becomes callous, with thickened borders; and if healing 
 finally occurs, in part or wholly, the resulting cicatrix will distort 
 the stomach, and perhaj^s cause pyloric stenosis. 
 
 Acute Gastric Ulcer, or Open Ulcer, is not very frequent in this country. 
 It affects especially anemic young people, especially women, from 
 eighteen to twenty-five years of age, and is as much a symptom of 
 their disease as the anemia itself. It is apt to give rise to hemorrhage 
 and to perforation. The ulcers usually are multiple; are round; 
 api)ear punched out of the gastric wall; and usually are from 0.5 to 
 1 cm. in diameter. 
 
 Symptoms. — The characteristic symptoms are severe Inirning pain 
 soon after eating, relieved by evacuation of the stomach either through 
 the pylorus or by vomiting. The pain seems to be due to the increased 
 acidity of the gastric juice caused by the process of digestion, as well 
 as to peristaltic movements and mechanical trauma by the food. 
 There is hyperacidity even of the empty stomach . Antacids thus relieve 
 the pain. iVn area of tenderness in the epigastrium is commonly pres- 
 ent, usually to the right of the median line; sometimes a similar tender 
 area is found just to the left, more rarely the right of the last two 
 dorsal vertebrae. Vomiting is frequent, often being self-induced to 
 relieve pain. The vomitus often is streaked with blood, and quite 
 independently of the ingestion of food hematemesis may occur. Pro- 
 fuse and prostrating hemorrhage usually is due to an erosion or an 
 exulceration; more moderate bleeding, especially if frequently recur- 
 rent, generally is due to the round open ulcer. 
 
 Chronic Gastric and Duodenal Ulcer; Cicatrizing or Callous Ulcer. — 
 This may be a later stage of the open ulcer already described, but it 
 seems clinically often to have been chronic from its commencement, 
 whatever its pathological origin. It is a much more frequent disease 
 in this country. It is this type of ulcer which is more often duodenal 
 than gastric. Mayo has established the position of the pyloric vein 
 
 1 The normal acidity of the gastric juice is equivalent to 0.48 per cent, hydro- 
 chloric acid. If a patient is reported to have a gastric acidity of 60, this signifies 
 that there is hyperchlorhydria. If, on the other hand, the total acidity is reported 
 as .30 or 20, the acidity is clearly below normal. The "free" acid of the gastric 
 juice normally varies between 0.1 and 0.2 per cent. 
 55 
 
866 SURGERY OF THE G ASTRO-INTESTINAL TRACT 
 
 as the dividing line, and classes the portion of the duodenum above 
 the bile papilla as gastric rather than intestinal in nature. 
 
 The ulcer, which usually is single, has thickened borders, and is 
 quite irregular in outline. Cicatrization leads to contraction, and 
 jiyloric stenosis (p. 868) is the most frequent result. If the ulcer is 
 situated on the lesser curvature, it often extends on both anterior and 
 posterior walls of the stomach (saddle ulcer) ; and its cicatrization may 
 produce hour-glass sfomach (p. 871). The chronic inflammatory 
 changes around the periphery of the ulcer are frequent forerunners 
 of carcinoma of the stomach (p. 873). 
 
 Symptoms. — These last a long time before relief is sought from 
 surgery, so that the patients usually are thirty-five to forty years 
 of age or older when first seen. The affection is commoner in men 
 than in women. Symptoms of dyspepsia overshadow everything 
 else. These dyspeptic attacks, characterized by flatulence, pain, 
 palpitations of the heart, epigastric distress, belching, sour eructa- 
 tions, nausea and even vomiting, occur in periods which last several 
 weeks at a time. During the intervals the patient suffers less, but is 
 not entirely free from symptoms. The pain and distress do not begin 
 until tliree or four hours after meals, and are relieved by ingestion 
 of more food (himger-pain of INIayo Robson). This is because the 
 excess of acid is neutralized by food. Patients are unwilling to go 
 without food for more than a few hours at a time. This constant 
 and regular recurrence of gastric dyspepsia several hours after meals 
 is particularly characteristic. The dyspepsia due to chronic appendi- 
 citis (p. 863) is both inconstant and irregular in its occurrence, and 
 is not relieved by eating. In chronic gastric or duodenal ulcer, how- 
 ever, the distress from indigestion may finally become so extreme, 
 that a patient will be unable to eat his full meals. He may be 
 reduced to carrying a bottle of milk around with him, taking a sip 
 every little while, to relieve the burning sensation in his stomach. 
 Hemorrhage, as has been remarked, is less usual in chronic than in 
 acute ulcer, and rarely is large in amount. If the ulcer is duodenal, 
 blood in the stools (melena) is more frequent than hematemesis; the 
 bleeding may be occult or visible to the naked eye. 
 
 Physical examination is of much less assistance at this stage of the 
 disease, than later, when pyloric obstruction has developed. Tender- 
 ness is rather diffuse; and occasionally a mass may be felt in the 
 pyloric region, and may be mistaken for carcinoma. 
 
 Prognosis and Treatment of Gastric and Duodenal Ulcer. — Hemor- 
 rhage kills about 5 per cent, of patients, and perforation about 15 per 
 cent. Of the 80 per cent, which remain, prompt, efficient, and pro- 
 longed medical treatment will cure perhaps three-fourths; but this 
 cure seldom is permanent. From 30 to 50 per cent, of patients so 
 cured have relapses, and though they may be "cured" a number of 
 times by resort to medical treatment, the cure usually is attained with 
 greater difficulty and is less lasting, after each new relapse. ]\Iean- 
 while the patient is subjected to the danger of hemorrhage and per- 
 
GASTUIC AM) Dl'ODENAL ULCER <S67 
 
 foration; and tlic (l('^•('l()I)IIUMlt of pyloric stenosis, liour-glass stomach, 
 or carcinoma is the usual termination in those i)atients who survive. 
 
 Medical treatment aims to encourage healing of the ulcer largely 
 hy reducing the acidity of the gastric juice. This is accomi)lished by 
 regulation of the diet and the ingestion of antacids. Surgical treat- 
 ment aims to eiVect a cure either by excision of the diseased structures, 
 or by altering the composition of the gastric juice more or less per- 
 manentl\- 1)\' admitting the alkaline duodenal secretions (bile and 
 pancreatic juice) into the stomach through a gastro-intestinal anasto- 
 mosis. The latter method, which still is more widely emi)l()yed than 
 excision, and which is more widely applicable, is attended by an opera- 
 ti\e mortalit.\' of o per cent., or less, in the hands of skilled abdominal 
 surgeons; and from 75 to 80 per cent, of the patients who recover 
 are permanently relieved of symptoms (Deaver and Ashhurst). It 
 is generally conceded, therefore, in patients whose symptoms recur 
 after one or several "medical cures," that surgical treatment is indi- 
 cated; and especially is this true of patients wuth recurring hemor- 
 rhage. Perforation of course calls for immediate operation. 
 
 Operation. — If the stomach is not bound down by adhesions, removal 
 of the entire ulcer-bearing area (Rodman, 1900), as in cases of car- 
 cinoma, is preferred by many surgeons; this is especially desirable 
 when there is much inflammatory thickening around the base of the 
 ulcer. The technique of this operation (partial gastrectomy) is 
 detailed at p. 881. Excision of an isolated ulcer may also be done. 
 In both cases a complementary gastrojejunostomy is done. The 
 mortality, even in skilful hands, is higher than that of simple gastro- 
 jejunostomy (p. 879), and I believe in most cases the latter 
 operation is to be preferred, unless the stomach is freely movable or 
 unless carcinoma is suspected. If there is no pyloric stenosis, it is 
 well to plicate the pylorus when gastrojejunostomy is done, since this 
 seems to accelerate the cure. It is well also to invert the ulcer by 
 a few sutures, as a prophylactic against subsequent perforation. 
 
 Perforation of Gastric or Duodenal Ulcer. — In most cases, unless the 
 patient is too ill to talk, he gives a history characteristic of the disease. 
 Perforation may be acute, suhacide, or chronic. An acute perforation 
 is one which occurs into the free peritoneal cavity, the base of the 
 ulcer having been unprotected by adhesions. A subacute perforation 
 is one w^hich occurs into such protecting adhesions. A chronic per- 
 foration occurs into an adherent viscus, such as pancreas, liver, colon, 
 gall-bladder, etc. 
 
 Acute perforation is characterized by very sudden, extremely severe 
 epigastric pain, often attended by shock. The patient doubles up 
 with pain, clutching at his abdomen, and even after being got to bed 
 may be found rolling around in agony, groaning constantly and secur- 
 ing no relief. Vomiting may or may not occur. Collapse is recognized 
 b}' the anxiety of countenance, the cold and clammy surface, the 
 sudden pallor and the guarded breathing. The pulse is feeble but 
 may be either slow or rapid at first. The abdomen presents truly a 
 
SG8 SURGERY OF THE GASTRO-INTESTJXAL TRACT 
 
 "board-like" rigidity, and as a consequence deej) palpation is valueless. 
 If the patient is not seen soon after the occurrence of perforation, the 
 effused gastric contents may have travelled down the right fiank to 
 the cecal region, and the case may be mistaken for appendicitis. 
 After six or eight hours, the abdomen becomes distended, secondary 
 vomiting commences, the pulse quickens and becomes more feeble, 
 and other signs of diffuse peritonitis (p. SOG) arise. 
 
 Treatment consists in immediate laparotomy through the upper 
 right rectus, and suture of the perforation, which usually is near the 
 pylorus. If suture is impossible, the perforation should be tamponed 
 with gauze. If operation is done within a few hours of perforation 
 and especially if suture stenoses the pylorus, or if the sutures tear out, 
 posterior gastro'ejunostomy should be done at the same time. In 
 many early cases the abdominal fluid is sterile, particularly if ])er- 
 f oration occurred in a fasting stomach, and perhaps because of the 
 hyperacidity of the gastric juice; but in all cases the pelvis should be 
 drained (through a suprapubic incision) as well as the upper a])dominal 
 wound. Subsequent treatment is the same as after any operation 
 for dift'use peritonitis. If operation is done within the first few hours 
 of perforation, the mortality is only about 15 per cent.; if postponed, 
 the death rate rises to 33 and to 50 per cent. 
 
 Suhaciite Perforation may be attended by the same type of symp- 
 toms, though less severe, as in acute perforation; or the condition may 
 be found unexpectedly at operation for the underlying disease. If 
 a subacute perforation is suspected in such a case, it is safer to do 
 gastrojejunostomy without disturbing the adhesions more than is 
 necessary. It may be Aery difficult to secure efficient closure of 
 such a perforation by suture. 
 
 In chronic perforation no additional symptoms are produced at the 
 actual moment when the gastric wall ceases to form the floor of the 
 ulcer and its place is taken by pancreatic tissue or by firm fibrino- 
 plastic material, so that the symptoms which first call attention to 
 the changed condition are not those of perforation nor of peritonitis, 
 but of sepsis due to some form of perigastric or subphrenic abscess, 
 or to some internal fistula. Treatment involves drainage of such an 
 abscess and operative cure of the gastric lesion. 
 
 Hemorrhage in Gastric and Duodenal Ulcers. — The diagnosis usually 
 is not difficult, but the diagnosis of gastric ulcer has been made in 
 cases of bleeding from esophageal varices. Treatment during continu- 
 ance of bleeding should be purely medical: morphin hypodermically, 
 an ice bag to the epigastrium, and nothing whatever by mouth. 
 Operation at this time is too dangerous to be recommended; the mor- 
 tality is from GO to 80 per cent. When the hemorrhage has ceased, 
 however, and the patient has regained some measure of health, opera- 
 tion should be done to cure the ulcer. Especially important is this 
 when repeated hemorrhage occurs. 
 
 Pyloric Obstruction. — This includes three distinct affections: 
 Infantile Pyloric Stenosis; Pylorospasm; Gastric Dilatation. 
 
I'YLOh'lC onSThTCTION 809 
 
 Infantile Stenosis of the Pylorus. —The baby usually is hcaltliy at 
 birth, l)u1 within a week or so develops the eoiulition (lescrilx'd as 
 hyperemesis lactantium. Unless arrested, the alVeetioii projijresses 
 until j;astrie piM-istalsis can be seen through the emaciated abtloniinal 
 wall, and a pyloric tumor can be felt. The obstruction usually i-s 
 due to excess of nuiscular tissue about the pylorus. The cause of this 
 change is not certain, but probably is hypertr()i)hic. In most cases 
 medical treatment brink's relief before complete obstruction develoj)s; 
 but unless loss of weight is checked very soon operation should be 
 done. Posterior gastrojejunostomy is the operation usually employed. 
 Nicoll ( lOOC)) has had nuich success with a special form of i)yloropliisty. 
 
 Pylorospasm. - This is an intermittent or constant contraction of 
 the pyloric sphincter, attended by more or less evident symptoms. 
 It is itself only a symptom of a lesion which may be in the stomach 
 or elsewhere. Pyloros])asm not infrequently accompanies gallstone 
 colic or aj)pendicitis. In many cases the pain is not very great, 
 amoimting merely to a lively sense of discomfort in the epigastric 
 region, and being overshadowed by symptoms of "peristaltic unrest 
 of the stomach" (Kussmaul, 1880): w'hen the pylorus contracts 
 spasmodically the stomach meets with an insuperable obstacle to its 
 evacuation; peristaltic unrest ensues, flatulence develops from fer- 
 mentation and from swallow^ed air; and, finally, when the limit of 
 endurance is reached, the pylorus relaxes and gastric contents pass 
 out into the duodenum or the patient is relieved of his distress by 
 vomiting. Secondary gastric dilatation may ensue. Treatment is that 
 of the causative condition. 
 
 Gastric Dilatation. — Acute Dilatation of the Stomach (Hilton 
 Fagge, 1872) is met with as a complication in various infectious 
 diseases, notably typhoid fever and pneumonia; as well as after some 
 operations, not always involving the abdomen. Though not caused 
 by pyloric obstruction, it seems best to mention the condition in this 
 place. 
 
 The stomach fills nearly the whole abdomen, and the site of apparent 
 obstruction usually is found at or near the duodenojejunal angle. 
 A physiological fact pointed out by Kelling (1900) may have some 
 bearing on the condition: this is that so long as the duodenum is 
 distended the stomach is unable to empty itself. Many surgeons still 
 support the theory of Hanau-Albrecht (1899), that acute dilatation 
 of the stomach is caused by constriction of the transverse duodenum 
 by the superior mesenteric artery, from the drag of the small intestines 
 (gastro-mesenteric ileus). 
 
 Vomiting is profuse and repeated, and there is little nausea; immense 
 cjuantities of fluid are brought up in this w^ay, demonstrating hyper- 
 secretion by the stomach. Gaseous distention is extreme, and the 
 outlines of the stomach may be recognized tlirough the abdominal 
 wall. When the stomach tube is passed there is an abundant escape 
 of odorless gas, with a gushing or gurgling sound, at times almost an 
 explosion. Marked flattening of the abdomen follows this evacuation, 
 
870 SURGERY OF THE GASTRO-INTESTINAL TRACT 
 
 but soon the stomach refills with fluid and air. Signs of collapse, 
 largely due to deprivation of the tissues of so much liquid, quickly 
 follow. Occasionally spontaneous relief occurs, and profuse diarrhea 
 ushers in convalescence. 
 
 Treatment. — Treatment consists in repeated use of the stomach 
 tube; and in placing the patient prone or on the left side, with the foot 
 of the bed elevated, with a view to overcoming an obstruction at the 
 duodenojejunal angle. Or the patient may assume the knee-chest 
 posture. Operation to relieve a kink, or to perform gastrojejunostomy 
 should be the last resort. 
 
 Secoxdary Gastric Dilatation. — This is not a distinct disease, 
 but is the terminal stage of some preexisting disease which causes 
 pyloric obstruction. The most frequent causes are carcinoma, chronic 
 gastric or duodenal ulcer, or perigastric adhesions usually due to 
 disease of the biliary tract. Benign pyloric obstruction usually is 
 due to contraction of ulcers near the pylorus. Occasionally in the 
 earlier stages of ulceration such hyperplastic reaction occurs as to 
 cause temporary obstruction of the pylorus; if gastrojejunostomy 
 is done at this stage the pylorus may subsequently become patulous, 
 just as it might have done if no operation had been employed. But 
 when cicatricial stenosis once develops the prognosis is hopeless with- 
 out operation. 
 
 Symptoms. — Tlu"ee stages are recognized : In the stage of compensa- 
 tion it is only after an unusually heavy meal that distress is experi- 
 enced; gaseous distention becomes oppressive, the clothing is perhaps 
 unconsciously loosened, and relief eventually is obtained by the 
 belching of gas and the eructation of a little sour fluid. Finally the 
 wearied stomach empties itself into the duodenum. This stage may 
 last for months or years, but eventually the .stage of stagnation is 
 developed: here the stomach is unable completely to evacuate its 
 contents between meals, except in the long interval at night. A sense 
 of fulness persists from one meal to the next, and anorexia develops. 
 Weight may not be lost, but none is gained. In the stage of retention 
 emaciation commences and may become extreme. The stomach 
 is not emptied e\en during the night; lavage before breakfast will 
 detect food particles still in the stomach, and the gastric contents 
 will be sour, rancid, and usually very acid. The evidences of fermenta- 
 tion are pronounced, and production of gas may continue after the 
 stomach contents have been removed, as is evidenced by their separa- 
 tion into three typical layers on standing. Because fluids are not 
 absorbed from the stomach, and because in this stage they are late 
 in reaching the small intestine, if they reach it at all, there is more 
 or less constant thirst. As retention becomes extreme, the stomach 
 occasionally makes an attempt to empty itself by the act of vomiting; 
 though generally incomplete evacuation is secured, temporary relief 
 is obtained. Copious and cumulative vomiting which occurs every 
 few days is very good evidence that the stomach is dilated. Occa- 
 sionallv tetanv occurs. 
 
HOUR-GLASS STOMACH 871 
 
 Physical IShjtus. Tlic capacity of the stuiiiacli is seen to be increased 
 not only from the large amount of the vomitus, but by lavage. Skiag- 
 raphy at various intervals after the ingestion of bismuth gruel will 
 demonstrate the gastric retention, and dilatation. The greater 
 curvature almost always is below the uml)ilicus and may reach to the 
 peKis. Tiie stomach may be cautiously distended with air by a hand 
 bulb attached to the stomach tube. The outlines can then be deter- 
 mined by i)ercussion. Analysis of the feces shows the solid matter 
 reduced to less than half the Jiormal of 4 to oz. in twenty-four hours; 
 while the proportion of water falls as low as 40 or even 30 i)er cent, 
 of normal. The urine also is diminished in quantity. 
 
 Diagnosis. — The diagnosis is based on a history indicative of a 
 previous disease which might cause pyloric obstruction, and upon the 
 existence of the symptoms and physical signs mentioned above. 
 In gasiroptosis , though the stomach may be dilated, there is no clinical 
 history characteristic of gastric ulcer or gall-stones. 
 
 Prognosis and Treatment. — This is the terminal stage of a serious 
 disease. Gastric dilatation due to benign obstruction is less serious 
 than gastric carcinoma only because patients with the former disease 
 die more slowly than do those with cancer. Cancer usually kills in a 
 shorter time, but death in benign dilatation is quite as sure even if 
 longer delayed. The starvation is slow, and it is barely possible that 
 the patient will not recognize the fact that he is starving to death; 
 yet he should be told that surgery affords the only escape from death. 
 A measure of comfort may be secured, in the earlier stages, by periodic 
 gastric lavage and careful regulation of diet; but no true improvement 
 takes place. What the surgeon urges is that operation shall be under- 
 taken while yet there is sufficient recuperative power left in the body 
 cells of the wretched patient. The choice of operation lies between 
 gastrojejunostomy, which is preferable in most cases; partial gas- 
 trectomy, which is indicated if malignancy is suspected; and some form 
 of pyloroplasty, which is not to be recommended except in patients 
 whose gastric motility is only slightly impaired. 
 
 Hour-glass Stomach. — As more than two pouches may exist, the 
 term segmented stomach (Wolfler, 1895) is preferable, though little 
 used. The deformity usually is the result of contraction of an ulcer, 
 but perigastric adhesions may be the cause, or even carcinoma (Fig. 
 849). The pouches may be of various sizes, or diverticula may exist.. 
 The sijmptoms seldom can be distinguished from those of pyloric 
 obstruction, which often is present as an additional complication; 
 and the diagnosis depends chiefly on the use of the stomach tube, 
 and filling the stomach with air or water, by means of which the exist- 
 ence of more than one compartment may be detected m many cases. 
 Often where no such abnormality exists, a skiagraph wdll show wdiat is 
 apparently an hour-glass constriction. Treatment consists in some 
 form of operation to overcome the obstruction. In gastroplasty (Fig. 
 850) an incision is made through the constriction in the long axis of 
 the stomach and is sutured transversely; the operation is analogous 
 
872 
 
 SURGERY OF THE GASTRO-INTESTINAL TRACT 
 
 to pyloroplasty (p. 878). In gasirogasirostomy (Fig. 851) a lateral 
 anastomosis is made between the adjacent pouches. Gastro-una.sto- 
 
 FiG. 849. — Hour-glass stomach from carcinomatous "saddle " ulcer on lesser curvature, 
 with perforation; death from peritonitis (half natural size). (Deaver and Ashhurst.) 
 Episcopal Hosjiital. 
 
 Fig. 850. — Gastroplasty. (Deaver and 
 Ashhurst.) 
 
 Fig. 851. — Gastro-gastrostoniy. 
 and Ashhurst.) 
 
 (Deaver 
 
 mosis (Fig. 852) is analogous to Finney's pyloroplasty (p. 879). In 
 the majority of cases gusirojcjnnostomy in the cardiac pouch is to be pre- 
 ferred to the operations just men- 
 tioned. As the cardiac pouch may 
 be so small as to pass unperceived, 
 the entire stomach should be ex- 
 amined before any operation is done. 
 If pyloric stenosis also is present, it 
 may be necessary todo pyloroplasty 
 in addition, or even to make a 
 second anastomosis, between the 
 jejunum and the pyloric pouch. 
 ^ , , • .T^ Plastic Linitis {Cirrhosis of the 
 
 -Ciastro-anastomosis. (Deaver o, i r, i i / 
 
 and Ashhurst.) Moiuach, Zuckerqiissmaqcu , Maqen- 
 
 FiG. 852. 
 
CAh'CLXOMA OF TUh' STOMACH S7.S 
 
 sclirutiipfiuuj, etc.) -This is a diU'iist' sclerosis of tlu' stoiiiacli, especially 
 of the subnuieous tissues, leading to marked thickening of the gastric 
 walls and diminution in the cajjacity of the stomach. It may be 
 benign or malignant in nature, and probably may arise in several 
 difi'erent diseases, such as carcinoma, syphilis, polyserositis, lymphatic 
 obstruction, etc. Thomson and Graham (191.'^) have reviewed the 
 subject at some length, and j^refer to term the condition a "fil)roma- 
 tosis." If the change is recognized early enough, j)artial gastrectomy 
 may be attempted; as a palliati\e measure gastro-enterostomy may 
 be (lone, or even duodenostomy or jejunostomy. 
 
 Gastroptosis. See Vis(er()ptosis, p. S9S. 
 
 Carcinoma of the Stomach. This is a very frequent disease, l)ut it 
 seldom is recognized in time to save the patient's life. About 75 
 per cent, of cases of gastric carcinoma can be shown by microscopic 
 study to have had their origin in chronic ulcer of the stomach. This 
 is an unansweral)le argument in favor of prompt and lasting cure of 
 such ulcers by surgical means. This class of patients with incipient 
 gastric cancer has been recognized only recently. Hitherto they have 
 been treated for chronic gastritis, dyspepsia, etc., and it was not until 
 frequent surgical intervention became the rule in such cases that it 
 was })roved that tlie change from the benign to the malignant state 
 manifests itself by no clinical symptoms. 
 
 Cancer of the stomach presents clinically two forms. In one a 
 patient past middle life, without having suffered previoush' from indi- 
 gestion, suddenly loses appetite, especially for meats, grows pro- 
 gressively weaker and more emaciated, develops epigastric pain and 
 possibly a palpable mass, becomes subject to vomiting spells every 
 few days, which bring up a quantity of coffee-ground material, foul 
 smelling and fermented; and quickly develops the cancerous cachexia. 
 This is the classical picture of gastric carcinoma, and it is still seen; 
 but it is very rare when compared with that other course of develop- 
 ment which I have just mentioned. Gastric carcinoma appears with 
 sudden onset in not more than 10 per cent, of cases. The second and 
 much more frequent course is found in patients who have been long 
 sufferers from dyspepsia. Medical treatment has given relief at times, 
 but indigestion recurs again and again. Appetite may be preserved, 
 but digestion is torture; so abstemiousness becomes the rule. There 
 may or there may not ha^•e been some period when gastric ulcer was 
 suspected or actually diagnosticated. Usually there have been no 
 very definite sj'mptoms. Finally these patients die; and at autopsy 
 a wide-spreading carcinomatous ulcer is found. 
 
 Pathology. — Carcinoma of the stomach occurs oftenest between the 
 ages of forty and seventy years, and affects the sexes about equally. 
 The gro\rth occurs at the pylorus in about 60 per cent., and at the lesser 
 curvature in about 10 per cent, of cases. Carcinoma of the body or 
 fundus is rare. 
 
 Histologically three types of gastric cancer are recognized : (1) 
 Spheroidal-celled carcinoma, composed of cells like those normally 
 
874 SURGERY OF THE GASTRO-INTESTINAL TRACT 
 
 lining the gastric tubules; (2) Cylindrical-celled or adeno-carcinoma, 
 composed of cells similar to those normally lining the gastric glands; 
 and (3) Colloid carcinoma, a tumor whose chief characteristic is 
 myxomatous degeneration of epithelial cells and stroma, which may 
 occur either in the spheroidal-celled or cylindrical-celled varieties. 
 Clinically carcinoma may be classed as scirrhous or medullary. 
 
 Lymphatic extension occurs early. The main paths in\'aded are 
 indicated in Fig. 853. Our knowledge of these lymphatics is due 
 almost entirely to Cuneo (1900), and to Jamieson and Dobson (1907). 
 Carcinoma, beginning as it usually does along the lesser curvature close 
 to the pylorus, invades first the lymphatics along the lesser curvature, 
 even up to the coronary artery close to the cardiac orifice of the 
 stomach. Hence it is evident that ever}' radical operation for gastric 
 
 Fig. 853. — Paths of lymphatic extension in carcinoma of the stomach. After 
 Jamieson and Dobson. 
 
 cancer must remove the entire lesser curvature of the stomach. More- 
 over, so soon as the carcinoma is at all extensive, the lymph nodes in 
 the gastro-colic omentum, for a variable distance away from the 
 pylorus, are involved. Therefore Hartmanns line for gastrectomy 
 (i901) was made to pass from the coronary artery to a point directly 
 below it on the greater curvature (Fig. 860). A third point of the 
 greatest importance is that whereas the carcinomatous, invasion extends 
 rapidly and for an indefinite distance away from the pyloric region 
 of the stomach, it invades the duodenum only rarely. The removal 
 of the first inch (2.5 cm.) of the duodenum nearly invariably enables 
 the surgeon to get beyond the limits of the growth. Palpable indura- 
 tion stops with the area of mucosa involved, but in the submucosa the 
 invasion will have advanced considerably further. The resection must 
 extend from 5 to 8 cm. away from the macroscopical tumor on the 
 cardiac side of the growth, and from 1.5 to 2 cm. from it on the 
 
CARCINOMA OF THE STOMACH S?;') 
 
 intrstinal side. Early lyiiii:)hatic extension, accortlinji; to Janiieson and 
 Dohson, also occurs along the inloric and hepatic arteries to the 
 sui)raj)ancreatic lymph nodes. 
 
 Apart from the lymph nodes, gastric carcinoma extends oftenest to 
 the liver, which is affected in one-third of the cases examined at 
 autopsy. This invasion occurs along the radicles of the portal vein. 
 In scirrhous carcinoma, and in all forms which cause marked ])yl()ric 
 stenosis, invasion of the liver is long delayed. Invasion of the great 
 omentum may be followed by grafting of cancer cells on the pelvic 
 organs. Invasion of the left supraclavicular lymph nodes, by permea- 
 tion along the thoracic duct, is a very late sign. 
 
 Symptoms. — ^Early diagnosis from symptoms alone is so difficult as 
 to be usually impossible. Almost always, by the time classical 
 symptoms have developed, the disease has passed beyond the stage 
 curable by excision, which is the only means of cure at present known. 
 
 Pain, vomiting, and tumor; loss of weight, anemia, and changes in 
 the gastric secretion are the classical symptoms. But their develop- 
 ment is so late that they do not bring the patient to the surgeon in 
 a curable stage. 
 
 Carcinoma should he suspected when chronic gastric catarrh exists 
 without any discoverable cause (such as abuse of food, of alcohol, 
 or of drugs ; circulatory disturbances of the heart or liver ; or diseases 
 such as cholelithiasis, gastric ulcer, etc., which cause definite lesions 
 in the region of the stomach) ; especially if the chronic gastritis is in a 
 patient over forty years of age, and if it is attended by loss of appetite 
 for meats. If a tumor exists, the diagnosis is less difficult; but the tumor 
 must be distinguished from a distended gall-bladder, from a growth 
 of the colon, pancreas, etc. In obscure cases distention of the stomach 
 with air should not be neglected; this may render a hidden tumor pal- 
 pable, and the characteristic shape of a pyloric growth (apex toward 
 the duodenum and indistinct base toward the body of the stomach) 
 frequently can be recognized (Kocher). Occult blood in the stomach 
 contents and feces is the most valuable of the laboratory findings. 
 In non-malignant ulcerations of the stomach, rest in bed with milk 
 diet will cause the disappearance of occult blood. In cancer no treat- 
 ment has any efi'ect (Deaver and Ashhurst). 
 
 Diagnosis. — The diagnosis can be only surmised in most cases still 
 in the operable stage; only v/hen the abdomen has been opened (and 
 not always then) can the surgeon be sure carcinoma is present. If 
 a distinct tumor is present, it generally can be recognized as carcino- 
 matous by its irregular shape, its " knotty" feel, and by diffused indura- 
 tion into surrounding structures. 
 
 Treatment. — Whenever there is evidence of an anatomical lesion 
 in the stomach which is not relieved by a few weeks of judicious 
 medical treatment, exploratory operation should be undertaken even 
 though an exact pathological diagnosis of the lesion has not been 
 reached. Partial gastrectomy (p. 881) should be done even on sus- 
 picion of malignancy. The immediate mortality of this operation is 
 
876 SURGERY OF THE GASTRO-INTESTINAL TRACT 
 
 about 25 per cent, in the hands of the average surgeon; even in the 
 hands of Robson, Mayo, Deaver, and other skilled abdominal surgeons 
 the mortality is from 5 to 10 per cent. The remote results indicate 
 that from 10 to 20 per cent, of patients with carcinoma of the stomach 
 who survive radical operation are cured of the disease, passing the three 
 and five year limits without recurrence. This is a creditable showing 
 considering that no other form of treatment offers even the shadow of 
 a chance for cure. Moreover, even if the patient ultimately dies from 
 recurrence or internal metastasis, his life is prolonged on the a^'erage 
 for eighteen months and most of this time is passed in comparative 
 comfort, and death finally comes in less hideous form: the patient 
 dies not of starvation but of cancerous cachexia. Even when removal 
 of the entire disease by operation seems impossible, many abdominal 
 surgeons think that life is prolonged and comfort promoted by removal 
 of the foul sloughing mass, discharging into the stomach. It is w^ell 
 recognized that gastro-enterostomy is not a good operation for such 
 cases; the immediate mortality is very high (15 to 25 per cent.), and 
 if the immediately fatal cases are included, the reckoning shows 
 survival is shorter than if no operation had been employed, while the 
 patients who survive suffer more than before the operation and may 
 live a longer time than if the abdomen had been closed without doing 
 gastro-enterostomy. Other palliative operations have been employed : 
 in carcinoma of the cardiac orifice gastrostomy has been done, but I 
 believe it is contraindicated so long as the patient can swallow fluids. 
 Jejunostomy and even duodenostomy (above the bile papilla) may be 
 employed as euthanasial measures in cases where the body of the 
 stomach is widely infiltrated and the patient is starving. In employ- 
 ing such operations the precarious state of the patient must be remem- 
 bered; the surgeon should know before beginning the operation just 
 what he intends to do, and then should do it without any unnecessary 
 intra-abdominal exploration. 
 
 OPERATIONS ON THE STOMACH. 
 
 Gastrotomy. — The operation of opening the stomach may be 
 required for the removal of foreign bodies within the stomach or 
 impacted in the lower end of the esophagus; or for purposes of explora- 
 tion. The abdominal incision is made through the upper left rectus 
 muscle, close to the median line. The stomach is located by finding 
 first the left lobe of the liver and tracing the gastro-hepatic omentum 
 down to the lesser curvature of the stomach. If a foreign body is to 
 be removed, it should be located if possible before opening the stomach. 
 After isolating the stomach with gauze packs, hold the foreign body 
 against the anterior wall of the stomach and cut directly down upon it, 
 making the incision just long enough to remove the foreign body. 
 Then repair the gastric incision with at least two rows of sutures 
 (p. <S,30), and close the abdominal incision without drainage. 
 
OI'Kh'ATIONS OX TIIE STOMACH 
 
 877 
 
 Gastrostomy. Tlir cstahlislimeiit of a gastric: fistula, for the purpose 
 of iutroduciuj;- food, is recpiircd most often in cases of imperiueal)le 
 stricture of tlic csoplia<;us (p. (195). The fistula should he made in the 
 pyloric antrum, and not in the fundus of the stomach. Several 
 methods of operating are in common use. 
 
 1. Stamius (1S94) or E. J. Scnns (1890) Metlml. —The anterior 
 gastric wall is drawn into the wound, and a small incision is made, 
 just large enough to admit the end of a good-sized catheter (No. 2(3 
 French). The catheter (its outer end clamped) is inserted for about 
 2 or 'A cm. inside the cavity of the stomach, and is fixed to the ga.stric 
 wall by a single catgut suture. 
 
 Then a purse-string suture of linen 
 is taken in the stomach wall, cir- 
 cularly around the catheter and 
 about 2 cm. distant from it; as 
 this suture is tightened the cath- 
 eter is pushed toward the cavity 
 of the stomach and carries with 
 it the gastric wall, which is thus 
 inverted so that the catheter lies 
 in a serous channel (Fig. 854). 
 Two other purse-string sutures 
 are similarly passed, and as each 
 is tightened the inverted cone 
 of gastric wall is lengthened, so 
 that finally the catheter lies in a 
 channel over 5 cm. in length. 
 
 The stomach is then sutured to the parietal peritoneum on both sides 
 of the abdominal wound, and this is closed around the catheter. 
 
 2. Kaders method (189G) is the same as Senn's except that the 
 puckering sutures to invert the gastric wall around the tube are not 
 passed as purse-strings, but as parallel sutures, one on each side of 
 the tube. 
 
 3. In WitzeVs method (1891) the tube is buried in an oblique manner 
 in the gastric wall, by means of Lembert sutures. After these sutures 
 are all tied, an opening is made in the gastric wall just large enough 
 to admit the end of the tube; and after this has been introduced and 
 fixed to the wall of the stomach with one catgut stitch, its point of 
 entrance is covered by a few additional Lembert sutures of linen. 
 
 The channel formed from the cavity of the stomach to the skin in 
 all these operations is absolutely continent so long as the catheter is 
 in place; when it is removed leakage may occur, but if the catheter 
 is left out for a long time the channel tends to close spontaneously, 
 owing to the adhesion of its serous surfaces. Liquids may be intro- 
 duced into the stomach through the tube at once if the patient is much 
 emaciated. During the intervals between feedings the tube should be 
 clamped, and it should be withdrawn for cleaning at least once daily 
 after the first few" da vs. 
 
 Fig. 854. — Gastrostomy by Stamm's 
 method. 
 
878 
 
 SURGERY OF THE GASTRO-INTESTINAL TRACT 
 
 Jejunostomy (p. 876) sometimes is employed as a substitute for 
 gastrostomy. Karewski (1896) adopted the technique employed by 
 Witzel for gastrostomy, while Mavdl (1898) employed a Y-anastomosis 
 
 (p. 8sn. 
 
 Fig. 855. — Incision for pyloroplasty. (See Fig. 856.) 
 
 Fig. 856. — Pyloroplasty, the incision through the pylorus ready for suturing. 
 
 Fig. 857. — Finney's method of pyloroplasty. 
 
 Pyloroplasty. — The operation for pyloric stenosis devised inde- 
 pendently by Heinecke and jMikulicz is seldom employed at present. 
 
OPERATIONS ON THE STOMACH 
 
 879 
 
 It consists in incisin*;- the pylorus in its long axis and th(Mi suturing 
 this incision transversely (Figs. S55 and Sf)!)). The incision should 
 extend from the stomach clear through the pylorus into the duodemmi. 
 The oi)eration is inefficient in preventing recurrence of stenosis, and 
 is un<lcsiral)le because it is necessary to work in diseased tissues. 
 The latt(M- objection ai)i)lies also to Finney's pyloroplasty (1002) which 
 is more efficient, however, because it approaches the type of a lateral 
 anastomosis between stomach and duodenum (Fig. S57). 
 
 Gastrojejunostomy. — An anastomosis between the stomach and 
 small intestine was first done in 1<S81 by Wolfler at the suggestion of 
 his assistant Nicoladoni. The 
 jejunum was anastomosed with 
 the anterior wall of the stomach, 
 for malignant obstruction of the 
 pylorus. In 1885 von Hacker 
 adopted a method of posterior 
 gastrojejunostomy, by anasto- 
 mosing a loop of the upper je- 
 junum with the posterior gastric 
 wall through an opening made 
 in the transverse meso-colon. 
 Most surgeons have now adopted 
 posterior gastrojejunostomy as 
 the method of choice, and use a 
 jejunal loop as short as possible, 
 as advised in 1901 by Petersen, 
 the assistant of Czerny (Fig. 
 858). 
 
 The indications for gastrojeju- 
 nostomy have already been con- 
 sidered. 
 
 The abdominal incision is made 
 through the upper right or left 
 rectus muscle close to the linea 
 alba. After careful exploration, 
 the great omentum and attached 
 transverse colon are drawn out of 
 the wound and pulled upward to 
 the patient's right, thus putting 
 transverse meso-colon on the 
 stretch, and bringing the origin 
 of the jejunum into sight. 
 The transverse meso-colon is 
 next torn tlirough in a bloodless area, by means of dissecting 
 forceps, and the opening is enlarged by the fingers in an antero- 
 posterior direction until it is from 8 to 10 cm. in length. The pos- 
 terior gastric wall is thus exposed and is made to protrude through 
 the meso-colon, whereupon it is grasped in an anastomosis forceps 
 
 Fig. 858. — Posterior retrocolic gastro- 
 jejunostomy. Note the absence of a loop 
 between the origin of the jejunum and the 
 site of anastomosis and the slight distortion 
 of the organs when the operation is com- 
 pleted. 
 
880 SURCERY OF THE GASTRO-1 XTESTI \AL TRACT 
 
 with nibVjer covered blades. At least 7.5 cm. of the gastric wall 
 should be grasped in this way. The portion grasped should be in the 
 pyloric antrum, and the forceps should l)e applied more or less trans- 
 versely to the long axis of the stomach. The jejunum, just below 
 the duodenojejunal juncture, is now brought forward, anfl a similar 
 fold of it is grasped in the other portion of the anastomosis forceps. 
 The jejunal loop should be applied to the stomach in such a way that 
 its aboral end is next the greater curvature of the stomach, and its 
 oral end next the lesser curvature. ]Moynihan prefers to have the 
 jejunum slant toward the patient's right; while ^layo turns it toward 
 the left. The gastric wall and jejunum being thus apposed, a typical 
 lateral anastomosis (p. 834) is made between them with needle and 
 tliread. The clamps are then released, and the edges of the opening 
 which was made in the transverse meso-colon are carefully sutured to 
 the gastric wall just above the anastomosis by three or four interrupted 
 sero-serous sutures. If this is neglected, a hernia of the small intestine 
 may occur alongside the anastomosis, into the lesser peritoneal cavity. 
 The abdominal contents are then replaced in proper position, and the 
 abdominal wound closed without drainage. Liquids may be given 
 in small amounts in twelve hours, but even semi-solid food should 
 be withheld for a week or ten days. 
 
 Anterior Gastrojejunostomy may be required when the posterior 
 wall of the stomach prcnes inaccessible on account of adhesions, etc. 
 A loop of jejunum about 35 cm. fl4 inches) long must be used, so as 
 not to constrict the transverse colon. If the operation must be com- 
 pleted with great speed, a Murphy button may be employed for the 
 anastomosis. 
 
 Posterior Gastrojejunostomy in Y. — This, which was adopted in 1897 
 by Roux of Lausanne, presents advantages in some ca.ses: the jejunum 
 is divided transversely about 35 cm. below its origin, and its aboral 
 segment is implanted into the posterior wall of the stomach tlirough an 
 opening in the transverse meso-colon. Then the oral segment of the 
 jejunum is implanted into the aboral segment about 15 cm. below the 
 gastro-jejunal anastomosis (Fig. 859). In this way there is no chance 
 for the duodenal secretions to reach the stomach, as they constantly 
 do when the usual anastomosis is done. The principle of the 
 Y-anastomosis is of value in certain ()Thcr intestinal anastomoses. 
 
 The Vicious Circle after Gastrojejimostomy is rarely seen at present. 
 When a long jejunal loop was used it was not infrequent. Probably 
 the cause is obstruction of the duodeno-jejunal loop at the point of 
 anastomosis. The patient vomits persistently after operation, and 
 if repeated lavage proves ineffectual the abdomen may have to be 
 re-opened to relieve the obstruction. The best treatment is an entero- 
 anastomosis between the afferent and efferent limbs of the jejunal 
 loop. The pylorus also should be occluded by a purse-string suture, 
 if still patulous. 
 
 A peptic ulcer of the jejunum occasionally forms at or below the 
 gastrojejunal anastomosis. It is seldom recognized except by hemor- 
 
OI'KUATIONS ON TIIK STOMACH 
 
 881 
 
 rha^v or p(.'rt\)rati()ii. Treatiuc'iit of these complications is the same 
 as that of gastric or duodenal ulcer. It may be necessary to make a 
 new gastrojejunostomy opening. This complication is rare after the 
 no-loo{) method of j)osterior gastro-enterostomy. 
 
 Fig. 859. — Diagram of posterior gastro-jojunostomy in Y, 
 
 Gastrectomy. — A portion or the whole of the stomach may be 
 removed. In pylorectomy the pylorus and some of the pyloric antrum 
 are removed; this operation is employed only in cases of benign 
 disease. In every case of malignant disease the whole of the lesser 
 curvature ought to be removed, and the operation is called a partial 
 gastrectomy, the stomach being divided at the Hartmann or ^Mikulicz 
 line (Fig. 800). If the stomach is removed as far as the Mayo line, the 
 operation is known as subtotal gastrectomy; while if the entire stomach 
 is removed from esophagus to duodenum, the procedure is worthy the 
 name of total gastrectomy. Circular or cylindrical gastrectomy desig- 
 nates an operation by which the central portion of the stomach, 
 including the entire circumference, is removed. 
 
 Partial Gastrectomy. — BiUroiKs First Method {IS>HI). — This operation 
 is very rarely employed. After removal of the diseased area, an end- 
 to-end anastomosis is made between the duodenum and the remaining 
 portion of the stomach (Fig. 861). As the circumference of the latter 
 56 
 
SS2 
 
 SLRdERY OF THE GASTRO-INTESTI XAL TRACT 
 
 is much greater tlian that of the duodenum leakajje is very apt to 
 occur at the "angle" of the suture lines. Kocher (1891) modified the 
 Billroth I technique by implanting the duodenum into the posterior 
 wall of the stomach, thus avoiding the deadly angle, and completely 
 closing the cut surface of the stomach. 
 
 Fig. 860. — Stomach, showing the Hart- 
 mann (H), Mikulicz (M), and Mayo (M') 
 lines. 
 
 Fig. 861. — Partial gastrectomj^ by Bill- 
 roth's first method. 
 
 Bill roth's Second Method. — In this both the duodenum and stomach 
 are closed completely, and the operation is terminated by a typical 
 ga.strojejunostomy. In Billroth's original technique an anterior gas- 
 trojejunostomy was done; but whenever possible posterior gastro- 
 jejunostomy is preferable. 
 
 The stomach is exposed through the usual right rectus incision, 
 and is isolated with gauze. "The coronary artery is identified, doubly 
 ligated and divided, close to the cardiac orifice of the stomach. The 
 finger is passed tlirough the gastrohepatic omentum into the lesser 
 peritoneal cavity, and the gastrohepatic omentum is ligated in sections 
 fairly close to the transverse fissure of the liver. By cutting through 
 the gastro-hepatic omentum the surgeon reaches the pyloric artery, 
 which is doubly ligated and cut. The finger is then passed down 
 behind the pylorus, and the right gastro-epiploic artery is identified 
 below the pylorus; this artery is ligated but not cut. Hemostatic 
 forceps are then applied to the gastro-colic omentum, and as they 
 are applied this structure is divided between them, beginning at the 
 pylorus and passing along the upper border of the transverse colon 
 until the point is reached at which it is proposed to divide the stomach. 
 This point should be two inches to the left of the visible malignant 
 growth. When this point has been reached the left gastro-epiploic 
 artery is ligated just to the left of the proposed gastric incision. In 
 
OI'I'lliAllONS ON THE STOMACH 
 
 ss.s 
 
 |)laciii<i; tlic lu'iii(»st;its on {\\v ^^astro-colic oiuciituiii, jfrciit care is to 
 be taken to a\ oid the middle colic artery and its branches. Tlie portion 
 of stomach to he rcmox'cd is now completclx' Treed alon<!; its curva- 
 tures, and remains attached only to the duodenum and the body of 
 tlie stomach. Tlie lesser jjcritoneal cavity can now he i)rotected 
 thoroughly hy sterile gauze compresses. A clamp with ruhher- 
 covered blades is now applied to the duodenum about one inch beyond 
 the portion xisibly diseased, and an ordinary clamp is a])])licd just to 
 the i)yloric side of the first clamp. The duodcinnn is then dixidcd 
 between the two, tlu' section cutting also the right gastro-epiploic 
 
 Fig. 8G2. — Partial gastrectomy: the duodenum has been divided, and the chimps are 
 in place for the gastric section. (Deaver and Ashhurst.) 
 
 artery (already ligated) below the pylorus. The entire portion of the 
 stomach to be excised can now be turned to the patient's left. The 
 duodenal stump is closed first by a through-and-through iodized 
 catgut suture; before the occluding clamp has been removed a purse- 
 string suture of linen is applied on the distal (duodenal) side of the 
 clamp; the clamp is then removed, and by catching the duodenal wall 
 in two places with dissecting forceps the sutured end of the duodenum 
 is inverted and the purse-string suture is drawn tight and tied (Fig. 
 862). The gastro-colic omentum is then ligated, and the hemostatic 
 forceps removed. Rubber-covered gastrectomy clamps are then applied 
 
884 SUKGEIiY OF THE GASTRO-INTESTJ NAL TRACT 
 
 across the stomach from the greater to the lesser curvature, at least 
 two inches to the left of the visible malignant growth. Clamps with 
 a screw lock at the end of the blades, as in Kocher's clamps, are safest. 
 About three-fourths of an inch to the right of this occluding clamp 
 an ordinary forceps is applied, and the stomach is divided between 
 the two with the thermo-cautery. The excised portion being removed, 
 a through-and-through suture of iodized catgut is inserted through 
 the margins of the gastric walls which protrude from between the 
 blades of the rubber-covered clamp. It is well to grasp these margins 
 at one or more points with forceps to prevent their retracting. When 
 the through-and-through sutures have been completed, the clamp is 
 remo\'ed, and a continuous sero-serous suture is applied burying the 
 first row." (Deaver and Ashhurst.) A posterior gastrojejunostomy is 
 then done, the viscera replaced, and the great omentum is drawn up 
 to cover the space left by the removal of the stomach. 
 
 Subtotal Gastrectomy differs from the oj^eration just described only 
 in the greater amount of stomach removed. Sometimes this is so great 
 that only an anterior gastrojejunostomy can be done to complete 
 the operation. 
 
 Total Gastrectomy proceeds along the same lines as partial gas- 
 trectomy; the duodenum should be sutured to the esophagus (end to 
 end) before the stomach is completely cut away from the latter. If 
 the duodenum, even after mobilization (p. 933) cannot be made to 
 reach the esophagus without undue tension, a loop of the jejunum 
 should be employed instead, being drawn through the transverse 
 meso-colon. The Y-anastomosis of Uoux is valuable under such 
 circumstances. 
 
 SURGERY OF THE INTESTINES. 
 
 Intestinal Obstruction, or Ileus, may be caused by: 
 
 1. Paralysis of the muscular tunic of the bowel {adynainlc ohsf ruc- 
 tion) from bacterial toxins, as frequently seen in cases of peritonitis 
 (p. 808), or from lesions of the spinal cord (p. 597). 
 
 2. Spasticity of the muscular tunic {dynamic obstruction) which is 
 very rare, and occurs chiefly in cases of lead or tyrotoxicon poisoning. 
 
 3. Occlusion of the intestine by (a) Changes within the lumen of the 
 bowel, such as impaction of feces, a gall-stone, or other foreign body 
 (obturation), (b) Changes in the wall of the bowel, such as congenital 
 malformations, or gradual occlusion by a tumor or contracting cicatrix. 
 (e) Pressure from the outside, by tumors of neighboring organs. 
 
 4. Strangulation of the intestine by (a) Peritoneal bands or adhe- 
 sions, (b) Intussusception, (c) Volvulus. {(I) Internal Hernia.' 
 
 Cases of intestinal obstruction are conveniently divided into two 
 classes, acute and chronic. Though cases of chronic obstruction 
 frequently become acute, and though acute cases very rarely may 
 
 1 Strangulation uf external hernia lui.s l)e(;n considered at p. 7()1. 
 
IXTKsriXAL OHSTHrcriOS NS.") 
 
 hfcome chronic, there is in most cases no difficulty in distiniinishing 
 one from tlie other. 'I'he acute cases are those (hie to .stm/Kjiilafion 
 or to ohfurafion from the sudden impaction of foreifjii bodies. The 
 chronic cases are ahnost solely those due to gradual occlusion of the 
 lumen of the howel hy a tumor or cicatrix or from pressure from with- 
 out. Ihnamic oh.struction is .scarcely a surjrical afi'ectioii. while ady- 
 namic «)l).struction has been sufficiently di.scussed with the subject 
 of peritonitis. Obstruction from congenital malformations usually 
 occurs at the rectum or anus, and is discussed at ]). 901. Affections 
 of Meckel's diverticulum are discussed at p. S91. 
 
 Acute Intestinal Obstruction. — The gravity of this condition 
 depend> not merely upon the arrest of the fecal current but upon 
 constitutional sxmptoms. The higher the obstruction occurs in the 
 intestinal tract the more quickly developed and the more pronounced 
 are these constitutional symptoms. Tlie collapse and other consti- 
 tutional symptoms of acute dilatation of the stomach have already 
 been noted (p. SOO). The exact cause of such constitutional symptoms 
 has not been determined, in spite of much recent experimental work 
 by Draper. Hoguet, and others. 
 
 Symptoms. — The local symptoms are well marked and easily recog- 
 nized: they are pain; vomiting; obstipation, with no passage of flatus 
 by the rectum; disordered peristalsis which is always audible 
 when the ear is placed on the belly, and may be visible if the 
 abdominal wall is thin; and finally distention of the abdomen. 
 The pain is characteristic; it is sudden in onset, very severe, 
 often causes the patient to cry out, and is intermittent. ^Yhen it 
 ceases the patient feels and may look perfectly well, but it returns 
 unexpectedly and with great suddenness. In most cases, within a 
 day or so, the pain becomes constant, and is more or less localized 
 to the seat of ob.struction. Sudden cessation of a fixed pain usually 
 indicates the occurrence of gangrene. The vomiting is projectile 
 in type: there is little or no nau.sea, and the patient, unprepared by 
 previous nausea, suddenly and unexpectedly spues forth a quantity 
 of vomitus all over everything. At first the vomiting is not very 
 frequent; the gastric and fluodenal contents are rejected first, later 
 the upper intestinal contents, and shortly before death matter that 
 appears fecal may be vomited. Though repeated enemas may secure 
 an evacuation from the bowel below the obstruction, no normal move- 
 ment occurs, and no flatus is passed by rectum at any time. Eventu- 
 ally the abdomen becomes tympanitic and distended and the peris- 
 taltic movements sometimes may be observed to be arrested at a 
 fixed spot, where the obstruction is located. The bowel above the 
 obstruction becomes much dilated and undergoes the changes already 
 described in strangulated hernia, that below the obstruction is col- 
 lapsed. 'The virulence of the bacteria above the obstruction is much 
 increased, and the altered intestinal wall is more readily traversed by 
 them, and thus peritonitis supervenes even before gangrene or per- 
 foration of the strangulated bowel takes place. Xot until this time is 
 
sso 
 
 SURGERY OF THE GASTRO-INTESTINAL TRACT 
 
 the temperature noticeably elevated, and though at this time also the 
 pulse becomes rapid and wiry, in the early stages of intestinal obstruc- 
 tion the pulse often is fuller and slower than normal. In this advanced 
 stage the diagnosis is difficult between i)erit()nitis with secondary 
 obstruction, and primary obstruction terminating in peritonitis. The 
 clinical picture is that of the late stages of peritonitis (p. 800). In 
 cases of acute intestinal obstruction, unrelieved by operation, death 
 usually occurs within a week. 
 
 Diagnosis. — The impaction of a biliary ndruJus or other foreign body 
 may be suspected from the history of the case, and from the inter- 
 mittent character of the symptoms, since the obstruction seldom is 
 absolute at first, the gall-stone shifting its position within the lumen 
 of the gut from time to time. It is most apt to become impacted in 
 the lower ileum. Obstruction from peritoneal adhesions, resulting in 
 kinks of the intestine or constriction beneath a band of organized 
 lymph is most frequent in children or young adults who give a history 
 of one or more attacks of peritonitis or of an abdominal operation. 
 The symptoms usually are very severe and collapse is marked. Intus- 
 susception is rare in those more than two years of age; usually it results 
 
 Fig. 863. — Diagram of an intussusception: A, the apex of the intussusceptum; 
 C, the collar of the intussuscipiens. 
 
 from violent peristalsis induced by enteritis; the presence of intestinal 
 parasites, polj^pi, or enlarged mesenteric lymph nodes may act as 
 predisposing causes. The most frequent form of invagination is the 
 ileo-cecal. The portion of intestine which is sucked down into the 
 lumen of that below is known as the intussusceptnm, while that which 
 receives it is called the intnss'iiscipien.s (Fig. 803). The apex of the 
 intussusceptum is that part which leads the way in the lumen of the 
 bowel (in an ileo-cecal intussusception the apex of the intussusceptum 
 is formed by the ileo-cecal valve) ; while the neck is the portion which 
 enters the collar of the intussuscipiens. The characteristic symptom 
 of this form of intestinal obstruction is the constant desire to defecate, 
 with the passage of blood and mucus from the rectum. Occasionally 
 the finger introduced into the rectum will feel the apex of the intus- 
 susceptum; and in many cases it is possible to recognize a sausage- 
 shaped tumor in the right or left hypochondrium, the right iliac region 
 being flattened (Dances sign, 1820), owing to the migration of the 
 invaginated bowel along the course of the ascending and transverse 
 colon. Volvidus is most frequent in adults, especially in the aged, 
 and is said to occur oftenest in the sigmoid flexure; but in my own 
 
INTESTINAL OJiSTUl ( TION 
 
 SS7 
 
 cxiHTiciKr till' siiinll intestine has hcen oftencst inxolxed. The ohstrnc- 
 tion is (hie to twisting' ot" the howel around its mesentery; unless an 
 are of three-Hlths of a circle is descrihed stranmihition does not occur. 
 The twist usually takes j)lace in contra-clockwise direction, the oral 
 linii) of the howel i)assinf^ ahove and to the right of the aboral limb. 
 \ Olvulus is predisposed to hy elonj^ation of the mesentery or hy fixa- 
 tion of the intestine at any point hy adiiesions, thus permitting; acti\'e 
 peristalsis to throw the oral limb over the aboral portion which is 
 fixed. Rectal examination sometimes reveals a distended coil of bowel 
 in the recto-vesical pouch; or the distended loop may be {)ali>able 
 throuiih the abdominal wall. Jnlcrnal hernia may occur in any of the 
 recesses or pockets of tlie j)eritoneum, especially the duodeno-jejunal 
 fossae; less often in the pericecal fossje or the meso-sigmoid fo.ssa. 
 
 Fifi. 864. — Strangulation of a loop of ileum through a hole in its mesentery. A 
 Meckel's diverticulum, adherent to the anterior abdominal wall prevented more intestine 
 from passing through the mesentery. Episcopal Hospital 
 
 Hernia through the foramen of Winslow is rare, as is a hernia through 
 a congenital or acquired opening in the mesentery of the small intestine 
 (Fig. S04). The possibility of a hernia through the transverse meso- 
 colon after the operation of gastro-jejunostomy has been mentioned 
 (p. 880). The diagnosis of these internal hernite is difficult; usually the 
 symptoms are gradual in onset, and many cases belong to the category 
 of chronic rather than to that of acute obstruction. Sometimes as 
 the hernia increases in size it may be discovered on palpation, or 
 borborygmi and subjective symptoms may point to the region of the 
 abdomen involved. 
 
 Treatment. — -The first and most important item of treatment is 
 to avoid ])iir(jafivrs. Even if the presence of obstruction is uncertain, 
 the administration of any form of la.xative or purge is absolutely con- 
 
88S ^URdERY OF THE (;ASTRO-INrESri NAL TRACT 
 
 traiiidicated, so long as the ])()ssil)ility of acute intestinal obstruction 
 cannot be excluded. It is perfectly proper to use enemas, in order to 
 secure an evacuation; but purgatives are not only useless, in that they 
 never relieve the obstruction, but they are intensely harmful. They 
 arouse peristalsis, which results in increase of the strangulation, and 
 they increase the amount of the intestinal contents above the obstruc- 
 tion. Some surgeons recommend the use of eserin, in cases of obstruc- 
 tion seen early; they argue that while it arouses peristalsis it does 
 not cause an exudation into the intestinal canal as most other purga- 
 tives do; and they believe that it will do good in cases of adynamic 
 obstruction, and that where the nature of the obstruction is uncertain 
 its use will aid the surgeon in reaching a diagnosis, since if nothing 
 is accomplished or the patient is made worse it may be assumed that 
 the obstruction is not adynamic but mechanical. This teaching I 
 regard as pernicious. Though I have seen eserin blow the wind out 
 of a belly with great activity, I have failed to observe that such an 
 occurrence hastens recovery; and I have also seen intestinal perfora- 
 tion caused by the violent peristalsis induced by eserin. It cannot 
 be too strongly impressed upon the student that in cases of adynamic 
 obstruction the patient is not ill because his abdomen is distended, 
 but his abdomen is distended because he is ill. 
 
 If there is any doubt as to the diagnosis, much less damage will be 
 done the patient by resort to immediate laparotomy than by pro- 
 crastination; and when operation is once seen to be indicated, there 
 should be no delay. The patient will not get any better by waiting. 
 But it is always well to wash out the stomach before operation. This 
 will prevent vomiting and perhaps aspiration of gastric contents into 
 the lungs while the patient is under ether. 
 
 Operation. — Unless the site of obstruction is definitely known, the 
 incision should be median, below the umbilicus. Do not let the dis- 
 tended intestines escape from the abdomen. Find the transverse 
 colon; it is recognized by the attached omentum. If it is distended, 
 the obstruction is lower, probably in the sigmoid or rectum, rarely 
 at the splenic flexure; if it is collapsed, the obstruction probably is in 
 the small intestine. Try to find some collapsed small intestine and 
 trace it upward to the obstruction. If evisceration becomes necessary, 
 the eviscerated intestines should be covered in hot wet towels, and 
 these should be kept hot and wet by constant irrigation with saline 
 solution at a temperature of about 115° F. If the bowel above the 
 obstruction is very much distended it should be emptied of its highly 
 infectious contents by aspiration or incision. Monks advocates passing 
 a glass tube up the lumen of the distended intestine, and crowding as 
 many coils of bowel upon it as possible, to aid in securing evacuation. 
 I have tried this method on several occasions, but have not found it 
 eflfectual. If the condition of the patient is very bad, the operation 
 may be terminated by establishing a false anus abo\'e the obstruction, 
 as in cases of acute obstruction superimposed upon clironic obstruction 
 (p. 890) ; and in almost moribund patients life is occasionally saved 
 
/.vv'A'.sv/.v.i/. oiisrurc'i'iox sso 
 
 l)y (tpciiiiii;- the fir.^t (list(Mi(l(Ml coil of iiitcstiiic wiiicli i)rt'S(>iits itself 
 without Miiikiiiic any search whatexer for the ohstriictioii; this con- 
 stitutes the old operation of nitrrotoni!/. It has recently been revixcd 
 l)\ Kro^ius 1 1!)1 1 ). If obstruction is due to the iniiMtrtion of a fort'tfiii 
 1x1(1 1/, it should he dislodged if jiossihie and removed throuf^h an inci- 
 sion in healtliN intestine. 
 
 If the ol)struction is due to ktnkiiKj from (tdhcsion.s, these usuallx' 
 may he se])arated with the fingers or gauze dissection; distinct hands 
 must he cut. The denuded areas on tlie intestines should be inverted 
 by sero-serous sutures, or should be covered with omentum. If the 
 adhesions an* \-ery wi(les])rea(l and the bowel very friable, a short- 
 circuiting operation (p. cSD.j) may be necessary. 
 
 In cases of Infuss^isception, efforts at reduction should be made l)y 
 pushing the intussusceptum l)ack, not by attempts to i)ull it out 
 from aboNc. The latter method rarely is successful, and may be pro- 
 ductive of much damage. If reduction proves impossible, the intus- 
 suscipiens may be incised longitudinally and the intussusceptum 
 removed, the incision being closed, and the neck and collar of the 
 invaginated bowel being sutured together as in Maunsell's method 
 of end-to-end anastomosis (Fig. 829). Enterectomy rarely is justi- 
 fiable in this or any form of acute obstruction; the establishment 
 of a false anus abo\e the obstruction (if this is not too high in the 
 intestinal tract) or a short-circuiting operation will be preferable. 
 Occasionally the gangrenous intussusceptum separates as a slough 
 and is discharged by rectum. The operative mortality is about 33 
 per cent. 
 
 In cases of voh-ulus, the bowel should be untwisted, and if the condi- 
 tion of the patient permits, it is well to take a reef in the redundant 
 mesentery or to attach the sigmoid to the parietal peritoneimi, so as to 
 prevent recurrence. 
 
 Chronic Intestinal Obstruction. — This is most often the result of 
 fecal impaction, benign or malignant stricture, or widespread peri- 
 toneal adhesions which interfere with peristalsis without causing 
 strangulation. 
 
 In fecal impaction, which occurs oftenest in the rectum or sigmoid, 
 rarely in the transxerse colon or cecum, there is obstinate constipa- 
 tion, with slight intermittent colicky pains from disordered peristalsis; 
 sometimes a mass can be felt through the abdominal wall, which is 
 recognized as fecal from its doughy consistency. Vomiting (never 
 stercoraceous) may occur during an acute attack; and watery diarrhea 
 often follows relief of the obstruction. Treatment comprises the use 
 of repeated enemas, administered in the Trendelenburg or knee- 
 chest posture, and evacuation of fecal masses from the rectal ampulla 
 by the finger if necessary. When once the impaction is relieved, it 
 is safe to give purges; as long as any acute symptoms persist opium 
 and belladonna may be of use in relaxing intestinal spasm. 
 
 In chronic obstruction from a cicatrix or tumor of the intestine, 
 the symptoms are much the same as in fecal impaction, but as a rule 
 
890 
 
 SURGERY OF THE GASTRO^INTESTINAL TRACT 
 
 no tumor can he felt. After many attacks of partial obstruction, this 
 is prone to become acute and complete at the last. If palliative treat- 
 ment (enemas) proves unavailing the surgeon should open the abdo- 
 men, and in the presence of acute obstruction should content himself 
 with making a false anus above the seat of the tumor; if there is no 
 evidence of acute obstruction the tumor or cicatrix may be resected, 
 but such a course almost always leads to death from peritonitis unless 
 the bowel above the tumor is unobstructed. If the tumor is in the 
 rectum, a sigmoid anus may be made in the left iliac region (Littre's 
 operation, 1710); but if the tumor is higher in the large intestine 
 cecostomy (Fig. 865) should be done in the right iliac region (Pillore, 
 1776). For obstruction in the small intestine, which is rare, a 
 short-circuiting operation is preferable (entero-enterostomy). 
 
 Fui. SOS. — Cecf)stf)nij', for .■icutc intestinal Dlisiruction. ul dw week's flurat.inn, super- 
 voniiis on chronic obstruction of twelve years' standing. Paul's tube in cecum. Stricture 
 of sigmoid, in woman of fifty-three years, following injury in childbirth thirteen years 
 ago. (See page 911.) Episcopal Hospital. 
 
 Mesenteric Thrombosis and Embolism. — Thrombosis of the mesen- 
 teric vessels occurs in many cases of intestinal obstruction, as the result 
 of strangulation. But thrombosis, and rarely embolism, may occur 
 as a primary condition, from the same causes which produce similar 
 conditions in other parts of the body. The sytnptoms are not unlike 
 those of acute intestinal obstruction, except that pain occasionally is 
 inconspicuous in cases of thrombosis; peritonitis develops more rapidly 
 than in intestinal obstruction; and there are evidences of hemorrhage 
 into the intestinal tract, with bloody diarrhea or \'omiting. Diagnosis 
 is difficult. Treatment comprises immediate laparotomy and resection 
 of the affected bowel, which quickly becomes gangrenous. Among 22 
 complete operations collected by Zesas (1910), there were 7 recoveries. 
 If the condition of the patient renders resection impossible, the gut 
 may be tamponed, or may be drained; but incomplete operations 
 almost alwavs terminate fatallv. 
 
IXTKSriXA L I'KRFOUA 770.V 
 
 891 
 
 h'l.Wlll.l '• '■!. .■' 
 
 
 ^>)vv 
 
 Meckel's diverticulum, the remains of the oinphalo-inesenteric 
 (hut, is loiiiid in al)()nt 2 jht eent. of bodies which conie to autopsy. 
 It is attached to the lower ileum, within a few feet of the cecum, and 
 usually springs from the anti-mesenteric border of the gut. It is 
 about the size of the finger, and may be unadherent, or may be attached 
 to the umbilicus (see I'mbilical Fistula) or to some other point in 
 the abdomen. It is most apt to cause trouble if adhereiit, acting as 
 a band under or around which the intestine becomes strangulated. 
 If adherent to the umbilicus, volvulus of the small intestine is fre- 
 (juent, causing torsion and per- 
 
 ha])s strangulation of the di\er- 
 ticulum (Fig. NdO). If unat- 
 tached, its chief afl'ection is 
 acute inflammation, which in 
 its pathogenesis, symptoma- 
 tology and treatment resembles 
 appendicitis. 
 
 Diagnosis. — The presence of 
 a Meckel's diverticulum may be 
 suspected if the umbilical cica- 
 trix is abnormal. I have twice 
 been able to make the correct 
 diagnosis before opening the 
 abdomen, by heeding this 
 maxim. Trouble is especially 
 apt to arise about the age of 
 puberty. 
 
 Treatment. — It is best to excise the diverticulum, at the same time 
 doing what is necessary to the strangulated intestine. 
 
 Umbilical Fistula. — If the omphalo-mesenteric duct remains patu- 
 lous, a fistula is present at the umbilicus. This may discharge feces, 
 or if very small only mucus. In some cases the discharge resembles 
 gastric juice and it is uncertain whether the mucosa from which the 
 discharge comes is an excluded part of Meckel's diverticulum, or 
 neoplastic ('adenomatous) in nature CDenuce, 1908). The best treat- 
 ment is extirpation of the diverticulum. 
 
 AflFections of the Urachus are rliscussed at p. 968. 
 
 Internal Fistulae of the Intestinal Tract usually are the result of 
 peritonitis, malignant disease, or tuberculosis. Occasionally they 
 result from injury. The existence of a fistula between the gall-hladder 
 and the intestine may be inferred if a large gall-stone is passed by rec- 
 tum or lodges in the intestine; such fistula? often close spontaneously 
 and rarely cause symptoms. A gastro-colic fistula gives evidence of 
 its presence chiefly by the development of lienteric diarrhea and 
 fecal vomiting. Other forms of internal fistula are rare and do not 
 cause characteristic symptoms. Gastro-colic fistula? scarcely ever 
 close spontaneously, and early operation is indicated. The best plan 
 is to separate the stomach and colon and repair the perforation in 
 
 Fig. 866. — Strangulation of Meckel's di- 
 verticulum, adherent to umbilicus. Age 
 forty-six years; duration two days. Epis- 
 copal Hospital. 
 
<S92 SURGERY OF THE (;ASTR0-I XTESTJ X AL TRACT - 
 
 each. But this is not always possible. Alternate inethods are (I) 
 section of the colon on each side of the fistula, and bilateral exclusion 
 (p. 895) of the portion of bowel containing the fistula, leaving it as a 
 pouch attached to the stomach, and reuniting the colon above and 
 below the seat of disease; (2) short-circuiting the fecal current by a 
 colo-colostomy (above and below the fistula ) or by ileo-sigmoidostomy ; 
 but neither of these y)lans is \-ery satisfactory. 
 
 Intestinal Perforation in Typhoid Fever occurs in about 2.5 per cent. 
 of cases. It is most frecjuent during the third or fourth weeks of the 
 disease and is predisposed to by a mixed infection in the intestinal 
 tract. The great majority of perforations occur in the ileum, within a 
 ffw feet of the cecum. The important symptoms are abdominal pain, 
 localized muscular rigidity, itwrease in the pulse rate, and often a fall 
 in the temperature immediately after the perforation. But the patient 
 may be too to.xic to complain of pain, and the other symptoms may 
 pass unnoticed unless the physician and nur.se are constantly alert. 
 Very soon rigidity is lost, distention commences, and often it is not 
 until widespread peritonitis is developed that the surgeon is asked 
 to see the patient. The sooner (operation is done, the better the chance 
 of recovery. Consent for immediate operati(jn should be obtained 
 before perforation occurs if its occurrence seems probable. If a pre- 
 perforative stage (peritonitis without symptoms of perforation) can 
 be recognized, it is proper to open the belly then, anfl to prevent 
 perforation by invercing all ulcers which threaten to perforate. Even 
 if no lesion is found (laparotomie blanche) the patient is none the 
 worse for the exploration. 
 
 The operation may be done under spinal or local anesthesia, but I 
 prefer a general anesthetic (ether or gasj. The incision, about '^ 
 inches long, is made through the right rectus muscle, below the umbili- 
 cus; and the lowest loop of ileum is pulled into the wound and traced 
 upward until the perforation (there may be more than one) is found 
 or until healthy bowel is reached. When a perforation is found it 
 should be closed by a purse-string or other appropriate suture (p. 
 829) in such a way as not to stenose the bowel. If the patient is des- 
 perately ill (no such patient is too near death for operation to offer a 
 chance of recovery) it is sufficient to drain the intestine above the area 
 of disease, by a Paul's tube (p. 915), tamponing the necrotic bowel. 
 Drainage to the pelvis always should be employed, but I consider 
 irrigation of the peritoneal cavity harmful. Subsequent treatment 
 is the same as for peritonitis. 
 
 In collective statistics (Harte and A-hhurst, 1904) the mortality 
 is nearly 75 per cent.; but a few indi\"idual operators report a death- 
 rate well below ()() per cent. (Montreal (jeneral Hospital, Johns Hop- 
 kins Hospital). In my own hands the mortality has been 62.5 per 
 cent.; this includes one patient who recovered after cholecystectomy 
 for perforation of the (jail-bladder during typhoid fever (Fig. S(i7), and a 
 case of recovery after removal of an acutely inflamed appendix during 
 typhoid fever. 
 
I'h-CAL riS'n LA 
 
 HWA 
 
 Intestinal Hemorrhage in Typhoid Fever is of sur<,M(al interest, 
 eliielly ui (•(iimect ioii with the diiij^iKtsis ot" pert'oPiit ion. In heinor- 
 rhiiye. tlioutih there iii;i\ he marked shock, increase of pulse rate and 
 fall of temperature, there seldom is pain or marked abdominal ri^iditx'; 
 and usually the Mood a|)|)ears in the stools within an hour or so. 
 
 Kiii. .s()7. 
 
 -fiall-hladder reinovpd lij- cholocystoetomy, showing typhoid pfiforalion. 
 (Natural size.) Episcopal Hospital. 
 
 Ill severe recurring- hemorrhages, which usually are fatal, Harte (1909) 
 advocates laparotomy; he succeeded in finding the bleeding spot by 
 the aid of transmitted light, and in checking the bleeding by suture. 
 Though his patients eventually succumbed, he has indicated the 
 proper course to pursue in such cases. 
 
 SljlS. — Diagram of a fecal fistula. 
 
 Fecal Fistula and False Anus. — If only a small portion of the 
 intestinal contents (perhaps only flatus) is passed from the bowel 
 through the opening in the abdominal wall, the patient is said to have 
 a fecal fififiild (Fig. SliS) ; but if practically the entire intestinal con- 
 tents are discharged in this way, a false anus (Fig. <S69) is said to 
 exist. 
 
 A fecal fistula sometimes develops in a drained abdominal wound 
 a few days after operation in cases where the bowel was gangrenous, 
 but the fecal discharge usually ceases spontaneously after removal 
 of the drainage, as the w^ound granulates. Its closure is aided by con- 
 fining the patient to as dry a diet as possible, and by securing an 
 evacuation through the rectum everv dav bv means of an enema. 
 
894 SURGERY OF THE GASTRO-IXTESTI X A L TRACT 
 
 Purges arc coiitraiiidicated. To ])revent excoriation of the skin around 
 the fistuLa, it may he i)ainted with colloiHon, with \\ liitehead's varnish 
 (p. (338), or covered with zinc oxide ointment. ^Mineral bases shoukl be 
 used in all such ointments, as animal bases sometimes are digested 
 by the intestinal juices. 
 
 A false anus usually is an artefact, intentionally produced by the 
 surgeon (Fig. 8S3); though it may also develop spontaneously, by the 
 gradual formation of a spur in a case of fecal fistula. It shows no ten- 
 dency to heal, owing to the presence of this firm s])ur between the affer- 
 ent and efterent loops of bowel; operation almost always is necessary to 
 secure its closure. In some cases, where it is certain that the afferent 
 and efferent loops of bowels are in close apposition, it is safe to destroy 
 the spur by passing one blade of a clamp into each opening and gradu- 
 ally tightening the clamp throughout a period of several days until 
 pressure has caused a slough to form, and converted the lumen of the 
 two intestines into one. Dupuytren's enterotome is the type of 
 instrument employed. If this can be satisfactorily accomplished the 
 
 Fig. 869. — Diagram of a false anus, with formation of a m.nrkcd spur. 
 
 external opening of the fistula usually closes spontaneoulsy. In most 
 cases, however, a radical operation must be done. This consists in dis- 
 secting widely around the false anus, opening the healthy peritoneal 
 cavity, which is well protected by gauze packs, and closing the open- 
 ing in the bowel by inversion of its margins where this is possible; 
 and in other cases by resection of the affected bowel, and restoration 
 of the continuity of the intestinal tract by end-to-end or lateral anas- 
 tomosis. 
 
 Tumors of the Intestine, except of the sigmoid and rectum (for 
 which see page 913) , are quite rare. Benign tumors are almost unknown 
 with the exception of mesenteric cysts (see below). Hyperplastic 
 tuberculosis and malignant tumors (sarcoma and carcinoma) produce 
 symptoms by obstructing the bowel. Sometimes melena or enter- 
 orrhagia occurs. If the tumor is recognized as soon as symptoms of 
 chronic obstruction appear, it is usually possible to remove it by intes- 
 tinal resection with fair prospect of ultimate recovery. Lymphatic 
 extension generally occurs late. In malignant tumors of the small 
 intestine resection with end-to-end or lateral anastomosis may be done. 
 
sch'c/'Hn' or tiik coi.ox asd siaMoin 
 
 M).") 
 
 In carciiioina ot" tlu- (renin (which sonictinics j^ivt's a palijahic tninor 
 helorc ohstruc'tive syniptoins arise) it is best to resect tlie entire 
 ileo-cecal coil of intestine as hi<i;li as the distrihntion of the middle 
 colic artery. The contimiity of tlie intestinal tract is restored by 
 implanting the ileum into the transverse colon or the sigmoid. If 
 resection is imix)ssihle in any case (and it never should be attempted 
 when acute obstruction has developed) a false anus may be estab- 
 lished above the sitt> of obstruction; or a short-circuiting operation 
 (Fig. S70) or an intestinal exclusion (Fig. .S71) may be performed. 
 
 Fiu. 870. — Ileo-sigmoidostomy, a typical 
 "short-circuitinf?" operation. 
 
 Fig. 871. — Unilateral exclusion of the 
 ascending colon, by implantation of the 
 ileum into the transverse colon. 
 
 Mesenteric Cysts usually are of embryonal origin, and are endo- 
 theliomatous in nature. Hydatid cysts, and cystic degenerations of 
 malignant tumors, also occur. Adhesions are common, but the 
 tumor usually is movable laterally; it is surrounded by a tympanitic 
 area, and may be crossed by a band of tympany. Its most frequent 
 site is in the mesentery of the low^er ileum. H. C. Deaver collected 
 40 cases in 1909. The proper treatment is extirpation, which often 
 involves resection of the overlying intestine. 
 
 Omental Cysts of the same nature occasionally occur. 
 
 SURGERY OF THE COLON AND SIGMOID. 
 
 Colitis. — Three types of this disease may be recognized: (1) Ordi- 
 nary ''catarrhal" colitis or entero-colitis, without known specific 
 cause, due originally to errors in diet, exposure, etc. (2) Bacillary 
 dysentery, due to the B. dysenteric of Shiga, which usually is an acute 
 disease and often rapidly fatal, and which is the common epidemic 
 form of dysentery wliich devastates camps, prisons, etc. (3) Amebic 
 dysentery caused by the amoeba dysenteriae (A. coli), which even 
 if acute or subacute at first almost always terminates as a chronic 
 disease. It is almost solely with the latter group of cases that surgery 
 
896 SURGERY OF THE GASTRO-INTESTIN AL TRACT 
 
 is concerned, since except in the rare event of perforation or abscess 
 formation the first and second are best treated medically. 
 
 In amebic dysentery the entire colon or only parts of it may he 
 affected. As the slou<jhs are cast off ulcers are left, and these may 
 cicatrize or perforate, while new ulcers are forming in other parts of 
 the colon. The sloughs may be passed by rectum in large masses 
 (membranous dysentery). The amebse are carried quite constantly 
 in the portal circulation to the liver, and hepatic abscess (p. 9.3()) is a 
 frequent sequel. 
 
 Symptoms. — The disease may begin acutely or so insidiously that 
 the patient is unaware of its existence and comes under the surgeon's 
 care first for the liver complication. A history of residence in the 
 tropics is then a great aid in diagnosis, though those who have never 
 been in the tropics may suffer from the disease. I'sually the ameba 
 may be found in the stools, especially after purgation. The symptoms 
 of the acute stages are frequent and copious watery and bloody dis- 
 discharges from the bowel, with much pain and loss of weight and 
 strength. Periods of remission are common, })ut recurrence of symp- 
 toms is almost inevitable. 
 
 Treatment. — The indications are (1) to destroy the parasites which 
 infest the bowel, and (2) to procure healing of the intestinal lesions. 
 Dieting, intestinal antiseptics, and rectal and colonic irrigations, which 
 comprise the medical treatment, rarely succeed in meeting these 
 indications, though they may secure alleviation or even latency of 
 symptoms. If symptoms recur persistently, it is best to resort to the 
 operation of cecostoniy, or that of appendicostomy (Weir, 1902); when 
 a fistula is thus established in the caput coli, irrigations can be much 
 more effectively used, and thus the operation affords a means of killing 
 the parasites and of curing the intestinal lesions. Cecostomy is done 
 by the method of Senn or AYitzel, for gastrostomy (p. <S77); appen- 
 dicostomy is accomplished by detaching the meso-appendix in part, 
 and suturing the appendix in the abdominal wound (Fig. 900). 
 
 Pericolitis, etc. — Of late years numerous cases have been observed 
 at operation in which there existed more or less definite symptoms of 
 chronic intestinal obstruction, of chronic appendicitis, etc., but in 
 which the main pathological changes consisted in the presence of broad 
 bands or membranes, binding the cecum to the parietal peritoneum, 
 holding the lower ileum in a kinked position, or fixing the sigmoid 
 so as greatly to interfere with its function. These membranes were 
 well described by Jabez X. Jackson in 1909 and are generally known 
 by the name of Jackson's membrane. The kink of the ileum (Fig. 872) 
 is especially associated with the name of Lane. 
 
 It is usually assumed, rather by exclusion than from any definite 
 reasons, that these membranes are the result of low grade infection. 
 Some are thought to l)e congenital in origin. But their exact path- 
 ogenesis is not known. 
 
 Symptoms. — The symptoms are subacute or chronic in type, antl, 
 according to Jackson, consist essentially in pain and tenderness, con- 
 
rii Id COLITIS 
 
 s\r» 
 
 stipatioii, miicdiis discliar^e from the bowel, meteorisni, loss of weight, 
 jiastric symptoms, and "neurasthenia. " 
 
 Treatment. 'IVeatment consists in (h\ision of the adhesions and 
 careful peritonization of all denuded surfaces. A diseased appendix or 
 gall-bladder, or other source of infection should be treate<l appro- 
 priately at the same time. 
 
 Fig. 872. — Kink of the ileum due to membrane binding it to the cecum, and associated 
 with chronic appendicitis. The appendix was much twisted and occupied a deep sub- 
 cecal fossa. From a patient in the Episcopal Hospital. 
 
 Pericolitis Sinistra. — When the sigmoid is affected the cause almost 
 always is infiammation of one or more of the diverticula so commonly 
 found there, and the pathological changes are somewhat different 
 from those encountered about the cecum and ascenrling colon. The 
 classification I suggested in 1907 includes: (1) Sigmoiditis, an inflam- 
 matory hyperplasia of the walls of the sigmoid, converting it into a 
 rigid tube, and usually causing a certain amount of obstruction. This 
 is comparatively rare. It may be caused by inflammation of a diver- 
 ticulum buried in the intestinal wall or in &n epiploic appendage. 
 (2) Perisigmoiditis, which usually is the result of inflammation of a 
 diverticulum projecting into the free peritoneal cavity. This may or 
 may not lead to perforation or abscess formation. The symptoms 
 resemble those of appendicitis, except that they occur on the left side, 
 and the treatment is the same, viz., excision of the diverticulum and 
 drainage of the abscess, or in rare cases resection of the diseased portion 
 of the sigmoid, especially if there is any suspicion of malignancy, 
 ."sigmoid diverticulitis has been particularly studied by Mayo (1907) 
 
898 
 
 SURGERY OF THE GASTRO^IXTESTIXAL TRACT 
 
 and by Brewer (1907). (3) Mesosigmoiditis: This again is most often 
 due to inflammation of a diverticulum lying within the layers of the 
 meso-sigmoid, or to an ulcer in the sigmoid. Sometimes a distinct 
 tumor is formed by the secondarily enlargeri lymph nodes (Fig. 873); 
 and sometimes tiie meso-sigmoid becomes contracted and distorted, 
 causing secomlary uli-tructive symptoms (Ries, 1907). 
 
 Cecum Mobile. — An unduly mov- 
 able cecum may l>e the cause of 
 many of the symptoms just de- 
 scribed, according to Wilms (190Sj. 
 This condition may be associated 
 with Lane's kink or with Jackson's 
 membrane, constricting the ascend- 
 ing cdldii or hepatic' flexure, and 
 is to be treated by suspension of 
 the cecum by suture to the parietal 
 peritoneum after removal of the 
 appendix and any adventitious 
 membrane present. 
 
 Flu. s7-i. — P.jLi.^v..-^,^! u'-.A'Auou: 
 complaints of backache and invalidism 
 for years. Episcopal Hospital. 
 
 Fig. S7.3. — Meso-sigmoiditis, in a child of 
 seven years. Recover}' after exploratory 
 laparotomy. Children's Hospital. 
 
 f"iij. ^7o. — Saruf- patit-iit a^r Fitr. ^74. 
 All symptoms relieved by wearing 
 suitable belt. 
 
 Visceroptosis. — Glenard, in 1885, drew attention to general visceral 
 prolapse, involving the hollow viscera, usually the right kidney, and 
 sometimes the liver and spleen as well. The deformity is more common 
 in women, and may or may not be associated with penduhus abdomen. 
 It is recognized now as not very rare in children, and is often held 
 
VllIiUMC IXTJ'JSTIXAL ,STAS1S 
 
 SO!) 
 
 r('sj)()iisil)l(' tor cliroiiic constipation. Oastroptosis, already inontioiicd 
 at p. S71. usually is a part of ji;(MU'ral visceral prolapse. In cases of 
 pendulous ahdonicn synii)toinsof sacro- 
 iliac relaxation (p. i')'.\!')) may arise, and 
 much comfort often he derived from 
 the use of an ahdominal helt (V\^. S75) 
 or properly fittinii; corset, thouf^h skia- 
 graphs made (after the use of bismuth 
 jijruel hy mouth or enema) before and 
 after the aj)i)lication of such a su])i)ort 
 do not show any noticeable chanj^e in 
 the position of the hollow viscera. 
 Relief probably is secured by over- 
 cominij static strain in the pelvic joints 
 and lumbar spine. 
 
 Chronic Constipation, which often is 
 due to some mechanical factor, such as 
 visceroptosis or one of the types of 
 pericolitis above described, is treated 
 by Lane by means of exclusion of the 
 colon by ileo-sigmoidostomy.^ In 
 some cases the entire colon is excised 
 at the same time or subsequently, 
 (^odman warns against accepting with- 
 out question the evidence of skia- 
 graphs made after the ingestion of 
 bismuth gruel as indicating true ob- 
 structive kinks in the large intestine, 
 since it has been found by Hertz that 
 fluoroscopic examination demonstrates 
 no obstruction to the onward course 
 of the intestinal contents even when 
 
 the kinks appear very pronounced. In most cases of chronic constijja- 
 tion the delay occurs in the pelvic colon, and not at the hepatic or 
 splenic flexures where kinks are most apparent. 
 
 1 According to Lane's theory most human ailments are due to "chronic intestinal 
 stasis:" the primary condition is some obstruction in the descending colon or 
 sigmoid; this results in cecal dilatation, and in attempts to overcome the obstruc- 
 tion adventitious attachments are formed around the cecum and lower ileum which 
 should be regarded as nature's efforts to fix the bowel in a more effective position. 
 Unfortunately this usually results in obstruction in the lower ileum; the weight 
 of the retained secretions in the jejuno-ileum causes a kink at the duodeno-jejunal 
 juncture, and again in an effort to overcome this nature produces adhesions around 
 the origin of the jejunum which may increase the obstruction, and by leading to 
 dilatation of the duodenum may be responsible for the development of duodenal 
 ulcer. Gastro-enterostomy Lane holds is effective merely because suspension of 
 the first jejunal loop to the stomach relieves obstruction at the duodeno-jejunal 
 juncture; the gastro-jejunal anastomosis is of no use whatever. The only rational 
 treatment for all these conditions he contends is section of the lower ileum and 
 union of its proximal end with the sigmoid below the last obstruction. In this 
 way he claims to have cured such diverse lesions as exophthalmic goitre, tuber- 
 culosis of the hip, trifacial neuralgia, etc., all of which he attributes to a primary 
 auto-intoxication from chronic intestinal stasis. 
 
 Fig. 876.— Congenital megacolon. 
 From a patient under the care of the 
 late Prof. Ashhurst in the University 
 Ho.spital. 
 
900 SURGERY OF THE GASTRO INTESTINAL TRACT 
 
 Congenital Megacolon. — This is believed by most patholojijists to 
 be really of congenital origin, as indicated by the name selected for 
 it by Hirschs])rnng in lcSS(). It is also known as IIir,sclifiprnn(fs 
 Disease. Whether or not there is always a mechanical obstruction, 
 or whether the dilatation of the colon is of neuropathic origin, are 
 questions still in dispute. The sigmoid flexure is usually, and the 
 entire colon often, involvecl; while the rectum and the small intestine 
 almost always escape the dilatation. Most patients come under 
 obserxation lietween the ages of two and ten years. Obstinate con- 
 stipation exists from very early life; the abdomen becomes immensely 
 distended (Fig. 87(i) ; the colon is packed with feces ; tympany may be 
 extreme at times; and the usual symptoms of fecal impaction are 
 present. The general health is impaired, and the child's growth may 
 be arrested. 
 
 Treatment. — Treatment in mild cases, and especially in \ery young 
 patients, should be palliative, as for any ordinary case of chronic 
 constipation. In others, operative treatment, which ofi'ers the only 
 hope of permanent cure, should not be delayed too long. Cecostom>' 
 I believe is the operation of choice; this is to be followed "by free 
 irrigations of the bowel through the fistula, and when the colon has 
 been well cleansed and the patient's health is improved, the entire 
 portion of bowel afl'ected is to be resected. 
 
 Tumors of the Sigmoid and Pelvic Colon are considered in con- 
 nection with those of the rectum (p. 913). 
 
 SURGERY OF THE RECTUM AND ANUS. 
 
 Examination of the Anus and Rectum. — Digital examination may 
 be employed with the patient on his back with thighs flexed, or stand- 
 ing in a stooping posture. The gloved finger, well lul)ricated with green 
 soap, is gently insinuated until both sphincters are passed, when its 
 tip will be in the rectum, which normally contains no feces. In men 
 the prostate and seminal vesicles can be felt beneath the anterior 
 rectal wall, and in women the cervix of the uterus usually can be felt. 
 Most pathological changes occur in or near the anal canal, and they 
 often are overlooked because the examiner expects to find them too 
 high in the rectum. If visual inspection is desired, it is necessary to 
 dilate the sphincter; this is best done under a general anesthetic. First 
 one index finger then the other is introduced, and by gradually sepa- 
 rating them in various diameters, the sphincter is dilated. Usually it 
 is desirable to dilate it until the finger comes into contact with the 
 tuberosity of the ischium on each side. The mere fact of dilatation 
 renders the anal canal visible, but to inspect the rectum high up, a 
 speculum (proctoscope) is necessary. Fig. 877 shows some convenient 
 types. The patient should lie on his back, with thighs well flexed on 
 the pelvis. The speculum is introduced gently, with the obturator in 
 place, and when introduced to its full depth the obturator is removed, 
 any fecal matter or mucus is sponged away, and as the speculum is 
 
sih'chun oi' rill-: i/hci'im wn wis 
 
 !)()1 
 
 slowly wit lidraw II llic iiiiitosa which |)r(»hii),s('> into its end is carc- 
 l'iill\ iiis|)(Mt(Ml Tor iihcrs. (hhitcd hemorrhoidal veins, orifices of 
 listuhe, etc. A siumoidoscopo is simihir to a |)roctoscoi)e, l)iit much 
 JoMjjor Ot* to II inches): it is inserted with j^reat care until its tip K^'ts 
 well beyond the hollow of the sacrum, and the bowel is examined 
 (by lijiht reflected from a head mirror, or preferably l)y means of 
 an incandescent bull) at the point of the instnnnent) from above 
 downward, as the instrument is withdraw ii. In most cases the instru- 
 ment does not really enter the siii;nioid, but the entire rectal canal 
 is readily seen, esi)ecially if the i)elvis is rais(>d so that the rectum 
 balloons. 
 
 Fig. 877. — Two forms of proctoscope, and a sijiimoidoscope. 
 
 Congenital Malformations. — These are due to failure of proper 
 union between the primitive proctodeum and the rectum (Figs. 878, 
 879, and 880). The most important classification is into those infants 
 with absolute occlusion of the rectal canal, and those in whom there 
 exists some form of fistulous exit for the meconium. In these latter 
 cases the rectum may empty into the urethra or the bladder, or in 
 the female into the vagina. In all except the last mentioned variety 
 the condition usually is recognized at birth, or within a few days, and 
 demands immediate operation. When the opening is into the vagina 
 no obstruction may occur, and the malformation may pass unnoticed 
 until adult life. 
 
 In any case the proctodeum may be present, as a dimple or shallow- 
 sinus at the normal site of the anus, the occlusion being above; or there 
 may l^e no e\idence of an anus. The most serious cases are those in 
 which the proctodeum is present and the occlusion so high in the 
 rectum or sigmoid that it cannot be recognized from below, but is 
 only inferred when symptoms of obstruction have been present for a 
 number of da\s. In such cases I believe it is safer to open the cecum 
 than the sigmoid, since the obstruction may be in the latter. 
 
902 
 
 SURGERY OF THE GASTRO-INTESriNAL TRACT 
 
 I demonstrated in 1907 that there are exceedingly few of these 
 cases in wliich the l)owel cannot be reached by a perineal operation; 
 and as the mortality of this operation is very much less than that of 
 iliac colostomy (Littre's operation, p. 890) which is the usual sub- 
 stitute, it cannot be too strongly emphasized that perineal proctoplasty 
 almost always may l)e successfully accomplished. An antero-posterior 
 incision is made in the perineum, over the normal site of the anus, 
 
 Fig. 878. — Congenitally imperforate 
 rectum, proctodeum absent. 
 
 Fig. 879. — Contrenitally imperforate 
 rectum, proctodeum present. 
 
 Fig. 880. — Congenitally imperforate rectum, the bowel opening into the urinary 
 
 tract. 
 
 from the base of the scrotum to the coccyx, and this is deepened, 
 keeping in the metlian line and following the curve of the sacrum, 
 until the rectal pouch is found. (I may go further, and advise, with 
 Stromeyer, even if the rectum cannot be found from below, that the 
 peritoneal cavity be opened through the perineum and any distended 
 loop of bowel found.) When the bowel is found, it is opened, and its 
 margins are drawn down and sutured to the skin. In newborn infants 
 
IS( ino-liFA'TA L A liHCEHS 
 
 903 
 
 tlic |)r()iii(»iit()r\ of the siicnmi is only '.\ to ') cm. (!', to 2 inches) 
 (listiiiit t'roin tlic amis, ami I liaxc on several occasions carried the 
 dissection as far as tiiis and succeeded in finding the rectum; and none 
 of the patients so treated (one of whom was two weeks old when 
 brought for oi)eration) has died. On the other hand, the only patient 
 on whom I ha\e been forced to do iliac colotomy (cecostomy) died 
 of inanition; this was a case in which no obstruction could be felt from 
 below, and where the autopsy showed there was agenesis of a portion 
 of the sigmoid, producing obstruction. In cases where the bowel 
 opens into the bladder or urethra it almost surely will be j)ossible to 
 reach the rectal ampulla from below, if nothing more radical can be 
 done the surgeon can at least establish a common perineal opening 
 for feces and urine, thus preventing temporarily ascending infection 
 of the urinary tract. When the child is older a more radical opera- 
 tion may be attempted. 
 
 When the bowel opens into the vagina, it is best to dissect the 
 rectum free, transplant the fistulous opening in it to the normal site 
 of the anus, and repair the vaginal opening (Uizzoli, 1856). 
 
 Abscess Around the Rectum and Anus. — This is a frequent affection, 
 and the abscess may occur in various situations (Fig. SSI): (1) .S'///;- 
 iegumental or perianal, which 
 is between the skin and the 
 external sphincter; (2) ischio- 
 redaJ, the most frequent of 
 all, which occupies the ischio- 
 rectal fossa, between the skin 
 and the levator ani muscle; 
 (3) submucous between the 
 mucous membrane of the 
 rectum and the internal 
 sphincter; (4) jjehi-rectal, 
 which develops above the 
 levator ani muscle, just out- 
 side the muscular w^all of the 
 bowel; and (5) retrorectal, 
 which is similar to the last named, except that it develops in 
 the hollow of the sacrum. As will be seen by reference to the 
 diagram all of these abscesses have their origin in the region of the 
 anus between the sphincters, and almost always they are the result 
 of slight trauma, from hardened feces, perhaps combined with exposure 
 to wet and cold. The patient complains of burning and scalding in 
 the rectum and great pain on defecation; it pains him to sit down; 
 and he may have retention of urine. 
 
 Ischio-rectal Abscess is most frequently seen. Examination in 
 the earliest stages shows merely a sense of resistance close to the 
 sphincter ani, with extreme tenderness. Later the whole ischio-rectal 
 region on one side may be tumefied, red, edematous, and pitting 
 on pressure. Occasionally the abscess bursts spontaneously into the 
 
 Fig. 881. — -Perianal abscesses. (See text.) 
 
904 
 
 SlIRdKRY OF TIIK CASTRO IM'MSl'INAL TRACT 
 
 rectum (l)etween the external and internal s])hincters) or on the 
 surface; hut usually it is so painful that surgical treatment is sought 
 quite early. Treatment consists in opening the abscess by an incision 
 radiating from the anus in the case of very small abscess; or by an 
 anteroposterior incision if the abscess is large. The incision must be 
 much longer than seems necessary, since it contracts \'ery rapidly 
 when the pus is discharged. The cavity is drained by a wick of gauze, 
 and is allowed to heal by granulation. Great care in dressing is 
 requisite to prevent damming up of pus. The affection is not usually 
 a serious one, but I have seen a few fatal cases in alcoholics and patients 
 otherwise unable to withstand infection. The siinis may be very slow 
 in healing, and fistula in ano is a frequent result, especially if rupture 
 into the bowel takes place. 
 
 The other forms of abscess mentioned require the same treatment, 
 but in those which lie above the external sphincter (submucous) it 
 is desirable to divide this also, as in fi.s-tula in ano, to secure better 
 drainage. A pelvi-rectal abscess should be opened by an incision in 
 the ischio-rectal fossa, after which the abscess is freely opened and 
 drained by puncturing the levator ani and then dilating it by 
 Hilton's method (p. 51). 
 
 Fistula in Ano. — The most frecpient cause of a fistula a})out the 
 anus is ischio-rectal abscess. 
 
 The fistula may have two openings, one on the skin surface (usually 
 over the ischio-rectal fossa) and the other on the mucous surface 
 (usually between the external and internal sphincters) ; this is known 
 as a complete fistula. Only one opening may exist, and this may be 
 on the skin surface (blind external fistula), or on the mucous surface 
 (blind internal fistnla). Sometimes there are two or more skin openings 
 to the same fistula, which may then resemble a horseshoe in form. 
 Occasionally several independent fistula^ exist. 
 
 
 Fig. 882. — FistuliB in ano: 1, complete fistula (usual form); 2, blind external 
 fistula (usual form); .3, blind internal fistula; 4, blind external fistula with suppurat- 
 ing tracts; 5, complete fistula entering the bowel above the internal sphincter. 
 
 Symptoms and Diagnosis. — The patient complains of a discharge of 
 pus, or an irritation of the skin around the anus. The external orifice 
 of the fistula usually is easily detected when the l)uttocks are separated; 
 it may be marked by a granulation or a tab of skin. The internal orifice 
 
FIsriLA AM) /'ISSIh'h' or Til/': AXIS «)().") 
 
 soinct iin('> ('ill I he IVIt l)y :i liiijicr in I lie rcct iiiii ;i> ;iii iiidiiratt-d .sj;()l, or 
 it may l)c made \ isihlc hy means of a rectal speeulnrn. The suj)j)urat- 
 iiii,^ tract which connects the two may he \ery dexioiis. IF it is desiretl 
 to |)rohe th(> fistuhi without K'^''"K '' K^'iieral anesthetic, the finder 
 shouM he intro(hiced into tlie rectum hefore the probe is passed into 
 the simis. I^\-er.\- fistuhi around the anus is not a fistuhi in aito; it 
 max he a ])ih)-ni(hd sinus (p. 2(')()) or the oi)eiiinfJj of a cold abscess in 
 connection with (hsease of the jx'Ivic bones or \'ertel)ral column; or, 
 more prol)ably, a fistula resulting- from a jjcri-urethral ai)scess (j). 1027). 
 
 Treatment. If the fistula is of very recent formation, palliative 
 treatment may l)e em])lo\'e<i. ( "auterization with sil\er nitrate or 
 chloride of zinc, or injections of bismuth paste sometimes })ring tem- 
 porary relief, but permanent cure without oj>erati<)n is very rare. 
 The classical operation consists in laying open the fistula from one 
 orifice to the other, by division of the external anal sphincter. A 
 grooved director is passed into the external opening of the fistula, is 
 caught l)y a finger as it emerges in the anal canal or rectum, and its 
 point is bent down and brought out of the anus, which is then slit tip 
 on the director as guide. In the case of external blind fi.stuhe the 
 director is passed into the sinus and is made to perforate the rectal 
 mucous membrane where this seems thinnest. A blind internal fisttila 
 may be opened up in similar manner after exposing its internal orifice. 
 When the fistula is once laid open, the cicatricial tissue lining it is 
 cut or scraped away, and the raw surface is packed and allowed to 
 heal by granulation. The sphincter should be cut transversely, not 
 obliquely to its fibres, and in not more than one place at the same 
 operation, even if several fistulae exist, for fear of producing inconti- 
 nence of feces. 
 
 Of late years many surgeons ha\e had much success in curing 
 fi.stula in ano by formal excision of the tract followed by immediate 
 closure by buried absorbable sutures; but the practice is not yet very 
 common. 
 
 Some of these fistula^ are tuberculous in nature; usually they develop 
 very insidiously, and usually a tuberculous focus exists elsewhere in 
 the body. Unless the other lesions are very far advanced, tuberculous 
 fistuhe should be treated by excision and suture, as those of simple 
 infiammatory nature. Scraping and leaving the wound open is apt 
 to result in recurrence. 
 
 Fissure of the Anus. — If a lump of hardened feces tears down one 
 of the anal vahes, the trauma is very apt to result in an indolent ulcer, 
 lying in the grasp of the external sphincter. The ulcer is placed 
 longitudinally in the anal canal, almost always at its posterior mid- 
 portion, and usually extends on to the skin surface. Almost unbearable 
 burning pain at the anus, after every act of defecation, and lasting 
 for an hour or more, is a highly characteristic symptom; and inspection 
 of the anus confirms the diagnosis. Digital examination of the anal 
 canal should not be made until the surgeon is ready to treat the lesion. 
 Very occasionally a recently formed fissure can be made to heal bv 
 
906 SURGERY OF THE (lASTRO-1 NTESTINAL TRACT 
 
 cauterization, application of a stimulating ointment, and scrupulous 
 cleanliness; but in most cases operation is required. This consists 
 in division of the sphincter through the base of the ulcer, under a 
 general anesthetic. Healing is then prompt under ordinary dressings. 
 
 Hemorrhoids or Piles. — A varicose condition of the rectal veins is 
 a ver}' frequent afi'ection. The inferior hemorrhoidal veins drain into 
 the internal pudic; the middle hemorrhoidals into the internal iliac or 
 one of its branches; while the superior hemorrhoidals are tributaries 
 of the portal system tlirough the inferior mesenteric vein. These 
 veins lie beneath the mucosa in loose areolar tissue, possess no valves, 
 and are therefore especially subject to the effects of gravity; there are 
 free anastomoses between the superior and the middle and inferior 
 hemorrhoidal veins, so that dilatation of one set is quickly succeeded 
 by dilatation of the others. In addition to the eflfect of gravity, which 
 is always acting, these veins are liable to distention from the pressure 
 of the contents of the rectum and sigmoid, from disturbances in the 
 portal circulation (which occur during every period of digestion, and 
 which pathological states frequently render constant), and from 
 pressure on the pelvic veins in cases of ovarian, uterine, or prostatic 
 disease. Straining in urination (as from stricture) as well as that 
 due to chronic constipation, is a frequent cause. 
 
 Hemorrhoids are classed as internal (which are covered with mucous 
 membrane) and external (covered by skin), or as inter o-external, 
 according to their relation to the sphincters. Hemorrhoids are further 
 classed as bleeding, inflamed, thrombosed, etc., terms which sufficiently 
 explain themselves. 
 
 The affection is commonest in adults, but is not very rare in the 
 young and the aged. External piles appear as protrusions of small 
 size, close around the anus; they are covered with normal skin, unless 
 inflamed, when they become purplish or red, swollen and very tender. 
 Suppuration may occur, and clotting of the contained blood is not 
 very unusual; in this w^ay a phlebolith may develop. The skin around 
 the anus may become much macerated, and at first glance the condition 
 may be mistaken for mucous patches; but the latter usually are not the 
 only signs of syphilis present, and frequently occur elsewhere as well 
 as around the anus. Internal piles are arranged in a circle just within 
 the sphincters; occasionally some are found higher up. They are 
 bluish-black protrusions beneath the mucous membrane, and are 
 easily compressible unless partly organized or thrombosed from 
 repeated attacks of inflammation. The piles become worse when the 
 paaent is constipated, and may protrude only when he strains at 
 stool or may come down on the slightest effort (Fig. 883), leading 
 eventually to prolapse of the rectum. There is a sense of fulness and 
 discomfort in the rectum almost all the time, and during a "fit of the 
 piles," when these structures become inflamed, the pain may be 
 almost unendurable and may radiate in various directions. Free 
 bleeding from the dilated veins usually brings relief, and is a rather 
 frequent occurrence, especially at the end of a bowel movement. The 
 
HEMOh'h'lloiDS 
 
 907 
 
 l)l()()(l is hri^'lit red, and appears spread oxer the tVcal masses, not 
 min^ded with tlien), as is hlood wliich conies from hi^dier up in the 
 intestinal tra<'t, and which is apt to l)e l)rown and clotted before it is 
 passed. 
 
 Fig. 883. — Internal hemorrhoids, protruding and bleeding. Episcopal Hosi)ital. 
 
 Treatment. — Any cause which can be discovered should be removed 
 if possible. In mild cases it is sufficient to attend to the state of the 
 bowels, procuring at least two free and soft motions daily by means 
 of dieting and mild laxatives, such as salines in the morning, senna, 
 rhubarb, etc. Active purges have little therapeutic effect though they 
 may be required to unload the rectum. Scrupulous cleanliness must 
 be preserved by irrigation or injections of cold water; protruding 
 piles should be pushed back after defecation; and some astringent 
 ointment (as one of equal parts of gall and stramonium ointment, 
 U. S. P.) may be applied to the anus. Should inflammation occur, 
 the patient should be confined to bed, with the pelvis slightly elevated; 
 and an ice bag or dry hot cloths may be applied locally. Moist heat 
 should be avoided. Much relief may be secured by the administration 
 of the following: I^ — E.ii. rhamni pursh. fl., fgss; ext. ergot, fl., f5j; 
 exi. hamamelis fl., f5iss. — M. S. — -Teaspoonfid in water ihree or four 
 times daily. Sometimes suppositories of opium, with acetate of lead 
 or tannic acid, prove useful. If thrombosis occurs and the pile is 
 excessively painful, it may be punctured and the clot evacuated. 
 Usually it is best to postpone more formal operative treatment until 
 the inflammation has subsided. Some surgeons employ palliative 
 operations, especially the injection of carbolic acid into the base of 
 each of the piles (one or two at each sitting) which are thus thrombosed 
 and may eventually shrivel up. I have no experience with this method 
 myself, but believe that as commonly employed it is neither efficient 
 nor entirely safe. Wallis prefers a 10 per cent, solution of carbolic 
 acid in glycerin and water; 3 to 8 minims are injected into the pile, 
 according to its size. He found his patients secured temporary relief. 
 
 Several radical operations are in common use for cases of hemor- 
 rhoids, the chief of which are ligation, clamp and cautery operation 
 
9()X SURGERY OF THE U ASTRO INTESTINAL TRACT 
 
 and excision. For the average operator there is no (loiil)t that the 
 first of these is the method of ehoiee both for safety and for certainty 
 of enre. For internal liemorrhoids J think it is preferabh- to cauteriza- 
 tion, though the latter is widely employed for these as well as for 
 external piles. Plxcision, the most radical of all, is a more formidable 
 operation, and though sufficiently simj)le to a skilled operator, entails 
 more risk to the ])atient. 
 
 Ligation of Hemorrhoids. — The anus is dilated as described at p. 900, 
 and each pile mass is caught in suitable forceps. Hemostatic forceps 
 are not efficient, as they usually tear loose. The Allis forceps or a 
 special ring forceps may be used. I'nless all the piles are clamped 
 in this way at one time, there will be danger of dislodging the ligatures 
 already placed while the remaining piles are being sought for. If there 
 is any pile which has a cutaneous margin (intero-external hemorrhoid) 
 a groove should be cut around its base through the skin with scissors; 
 this prevents the ligature from slipping, and by severing the skin 
 nerves reduces the discomfort after operation. A groove may be 
 cut also in the mucous membrane, all around the base of the pile, 
 exposing its pedicle, but this is not necessary. Then a curved needle 
 carrying a long, stout, linen thread is made to transfix the base of the 
 pile, in the long axis of the rectum; the loop of the thread is cut and 
 the pile is ligated in two sections, the ligatures interlocking and being 
 tied in the groove already out. The protruding portion of the hem- 
 orrhoid is then cut away leaving enough stump to prevent slipping 
 of the ligature. The ends of the latter should be left long until it has 
 been ascertained that no bleeding occurs. Each pile mass (usually 
 there are not more than five) is treated in the same way. Finally the 
 surfaces of the amputated piles are dusted with iodoform powder, and 
 a sterile pad is applied to the anus and held in place by a T-bandage. 
 Usually the bowels move spontaneously by the fourth da}\ If tJiey 
 do not they should be opened by a dose of castor oil. An enema should 
 not be given. Particular attention to local cleanliness and efficient 
 drying should be enforced for two wrecks; usually the patient may 
 leave bed in a week or ten days after operation. 
 
 Clamp and Cautery for Hemorrhoids. — After dilating the sphincter 
 and grasping all the piles in suitable forceps as already advised a special 
 pile clamp is applied to one of the masses, in the long axis of the 
 bowel, and is screwed so tight as to crush the base of the pile. The 
 protruding tissue is cut away, and the stump in the grasp of the pile- 
 clamp is cauterized with the cautery at a dull (cherry) red heat. 
 Though the pile-clamp usuall}' has its under surface faced with ivory, 
 to prevent radiation of the heat to the surrounding tissues, it is well 
 as an additional safeguard to surround it with damp cloths while 
 the cautery is in use. Each pile mass in turn is treated in similar 
 fashion, and subsequent treatment is conducted as already described. 
 Excision of Hemorrhoids (Whitehead, 1882). — An incision is made 
 in a circle around the muco-cutaneous juncture of the anus, and 
 the mucous membrane including the pile-bearing tissue is dissected 
 
I'h'oLM'SK OF riih: h'j'jci'r.M 
 
 !)(l!) 
 
 upward with siiii)s of the scissors and <;au/,(' pressure, until liealtliy 
 unicous lucuiliraiie is reached on all sides, 'i'he diseased cufi' of 
 nuicous uieuihrane is then excised, and the uuicous ineinhrane above 
 is united to the skin below by a continuous suture of chromic catgut. 
 If properl\ done there is very little hemorrhage, as the varicose veins 
 tluMuseh es are not opened; and there is little chance of stricture result- 
 ing unless infectit)n occurs. Frecfucntly the mucous membrane and 
 skin separate slightly at one or more points, but this does not occur 
 until granulation tissue has formed. 
 
 Prolapse of the Rectum. — This develops as the result of repeated 
 straining efforts, as in cases of hemorrhoids with constipation or in 
 severe diarrhea with rectal tenesmus, or sometimes as the resuit of 
 whooj)ing cough. The loose mucous membrane protrudes from the 
 anus at first only during defecation, and may recede spontaneously 
 when the patient stands up. Later, however, the bowel may protrude 
 at other times and may require to be replaced maiuially. Occasionally 
 reposition becomes impossible; in such cases usually the muscular 
 wall of the rectum has prolapsed also (procidentia recti). 
 
 The condition is most common in young children, but occurs also 
 in adults, and sometimes during old age when it often seems to depend 
 on loss of muscular tone. In every such case examination should be 
 made to exclude the presence of polypus, stricture, or carcinoma 
 higher up in the bowel. 
 
 Fig. 884. — Prolapse of rectum. Children's Hospital. 
 
 Symptoms. — In the ordinary form (prolapsus recti or partial prolapse) 
 the mucous membrane of the rectum is seen protruding from the anus 
 as a red or purplish ring. Usually the condition is unmistakable 
 (Fig. SS4). In c()m|)lete prolapse (procidentia) the jirotrusion may be 
 several inches in depth, and there is a clearly recognized groove between 
 the mucous membrane and the anus. Prolapse causes a sense of weight 
 and weakness, and often some disturbance of the urinary functions. 
 Strangulation is rare, but is seen occasionally at the first onset of 
 the prolapse; when the condition becomes chronic the sphincters 
 are much relaxed, 
 
91Q SURGERY OF THE GASTRO INTESTINAL TRACT 
 
 Treatment. — Reduction usually may be secured by moderate pressure 
 with an oiled cloth or the gloved hand, while the patient is lying prone. 
 In cases of strangulation it may be necessary to divide the sphincter. 
 Recurrence often may be avoided by having the bowels opened only 
 when the patient is lying down flat on his back. Moreover, the 
 buttocks should be strapped together by adhesive plaster, which is 
 removed only after the bowels ha\-e acted, and is at once replaced 
 when the parts have been cleansed. In the case of most children, in 
 whom the condition is not of very long standing, a cure results if the 
 child is kept in bed with proper regulation of diet and bowels. Cod- 
 liver oil is valuable as a tonic for these purposes. If operation is 
 required trial should first be made of cauterization as in the case of 
 hemorrhoids, clamping, excising, and cauterizing longitudinal folds 
 of mucous membrane down to within a half inch of the anal margin. 
 Or Whitehead's operation may be done. In Gersiinys operation 
 (1893) the anal canal is dissected free of all attachments and is 
 twisted on itself until a feeling of resistance is encountered and 
 then is sutured in its new position.^ In Schomacker's operation a 
 part of each gluteus maximus is transplanted around the anus, one 
 in front and one behind; the muscular flaps are then sutured to each 
 other. Mummery's operation (1910) consists in opening the space 
 between the rectum and sacrum by a transverse incision, packing 
 it full of gauze, and allowing it to heal by granulation. The patient 
 should remain in bed for a month. Mummery had complete success 
 with this method in four cases of severe procidentia. After recovery 
 the posterior rectal wall is firmly attached to the hollow of the sacrum 
 by fibrous tissue. Sutures were used (instead of gauze packing) by 
 Verneuil (18S9), Fowler (1897), and recently by Ekehorn (1909). 
 Sigmoidopexy, or suspension of the sigmoid to the anterior abdominal 
 wall, first employed in 1889 by Verneuil, is the most radical of these 
 operations for procidentia; but it is wise to combine it with a plastic 
 operation below, as recurrence has taken place in more than half the 
 cases treated by sigmoidopexy alone (Pachinio, 1905). Jeannel's 
 operation included also the formation of a false anus. 
 
 Proctitis. — Inflammation of the rectum may be traumatic (from 
 impaction of feces, frequent use of enemas, foreign bodies, etc.) or 
 infectious (dysenteric, septic, gonococcic, etc.). The symptoms are 
 a sense of heat, tenesmus, frequent, small, watery stools, often with 
 blood and mucus. There may be considerable fever and much con- 
 stitutional disturbance. Examination through a speculum shows 
 inflamed mucous membrane, and frequently patches of lymph covering 
 ulcers which bleed readily when touched. Treatment involves removal 
 of the cause when this is possible and known; also cleansing and anti- 
 septic applications through a speculum. After an ordinary cleansing 
 
 1 Chetwood (1902) employs a similar operation for fecal incontinence; and it 
 was for this purpose that Gersuny's operation was originally devised, based on his 
 experience (1889) with enuresis. 
 
sTUicrriiKs (IF rill': in-jriM '.ill 
 
 fii(.'in;i, ill srxtTc cases, tlu' patiriil may hr ctlierizcd, and a 2 \)vv ('ciit. 
 solution of silver nitrate swabbed all over the inflamed surfaces, 
 throuf^li a speculum. Then the rectum is irrif^ated with boric acid 
 solution (half saturated), and finally an injection is fjiven of a few 
 ounces of some denuilcent solution (flaxseed or slippery elm), contain- 
 ing 10 drops of laudanum (Abbe); this is to be retained as lonj^ as 
 possible. In mo.st cases two or three such treatments at intervals of a 
 few days arrest the disease. But in cases where colitis also exists 
 (dy.senteric, tuberculous), recurrence is the rule unless the ulcers 
 above can be made to heal by a})propriate treatment (p. 89(j). 
 
 Strictures of the Rectum. These are a frequent result of dysenteric 
 ulceration and of trauma in childbirth (Fig. SI)")). ^Malignant ulcera- 
 tion causing obstruction is considered under the heading "^Fumors of 
 tlie Rectum (j). 91))). Inflammatory changes in neighboring structures 
 (vagina, broad ligaments of uterus, pelvic connective tissue, prostate, 
 etc.) frequently extend to the fibrous tissue in the layers of the rectal 
 wall and they may cause a .submucous or perirectal stricture which is 
 the same in its effects as one which arises in ulceration of the mucous 
 membrane, since no ulceration of the mucous membrane which does 
 not involve the fibrous tissue can produce a stricture. Other causes 
 than those already mentioned are rare, though tuberculous and 
 syphilitic and other specific ulcerations and strictures do occur. 
 Syphilitic stricture, formerly considered frecjuent, is now acknowl- 
 edged to be quite rare. When these specific ulcerations occur their 
 pathology is much the same as that of septic or traumatic ulceration, 
 since secondary infection from the intestinal contents is the rule. 
 
 Almost all strictures occur within three or four inches of the anus; 
 those which occur higher, in the sigmoid or colon produce the symp- 
 toms of chronic intestinal obstruction (p. 889). The stricture may 
 be single or multiple, marginal or annular, of large or small calibre. 
 The simple inflammatory stricture, according to Tuttle, usually 
 occupies only a portion of the circumference of the bowel, stands out 
 abruptly from the rectal wall, usually is close to the anus, and has a 
 smooth surface covered with epithelium. A syphilitic stricture 
 presents a gradual funnel-shaped contraction, there is a bluish-white 
 cicatrix around the edges of the ulcer, and the floor of the ulcer is 
 excavated; the edges of a tuberculous ulceration always are undermined 
 and its base is elevated (Tuttle). Secondary ulceration, from fecal 
 impaction, occurs above the stricture, so that when these patients 
 come for treatment the rectum almost always is ulcerated as well as 
 strictured, though the ulcers w^hich were the original cause of the 
 stricture may have healed long since. 
 
 Symptoms. — These may not develop for years after the proctitis 
 which is the original cause of the stricture. The patient may come 
 complaining of frequency of urination with a sense of weight in the 
 perineum, and the importance of thorough local examination cannot 
 be too often emphasized. There is a history of the primary rectal 
 condition, followed by a latent period, and then gradually developing 
 
1)12 SURGERY OF THE CASTRO-INTESTINAL TRACT 
 
 but steadily increasing- difficulty in obtaining complete evacuation of 
 the rectum. As secondary ulceration develops, l)lood and mucus are 
 discharged with the stools, or frequently alone, the stricture retaining 
 the fecal mass above it. The diagnosis of simple from malignant 
 stricture is made by observing the long duration of the simple 
 stricture and the comparatively slight impairment of the general 
 health; and by direct examination of the rectum, when the smooth, 
 hard, but not nodular character of the stricture determines it to be 
 non-malignant. Malignant stricture is very rare before thirty-five or 
 forty years of age; its course is rajiid and progressive (two to three 
 years); loss of flesh and strength appears early; the tumor is nodular 
 to the touch and bulges into the lumen of the bowel as well as causes 
 fibrous thickening of its coats; and the odor of the discharge is 
 gangrenous, never simi)ly fecal (Tuttle). 
 
 Treatment. — Permanent cure cannot be hoped for from jxilliafive 
 frcdfittent with rectal bougies; they are of benefit even temporarily 
 only when the stricture is of recent formation; they must be passed 
 at intervals throughout the patient's life; and in many cases serve 
 only to aggravate the patient's discomfort by producing bleeding 
 and further ulceration, even if skilfully and gently passed. An 
 ordinary wax candle, molded by heat to suitable shape, makes as 
 good a bougie as any, provided the stricture is not very small and 
 is close to the anus. In other cases it is best to use the hollow bougie 
 of Wales, which is introduced through a speculum passed up to the 
 face of the stricture, and by means of which irrigation may be practised 
 above the stricture. Before operative treatmeni is undertaken it is 
 important to cleanse the bowel above the stricture. If this cannot be 
 accomplished from below (by repeated enemas or colonic irrigations 
 through a Wales's bougie, aided by the use of olive oil or gentle saline 
 purges by mouth), it is necessary to flo colostomy (sigmoidostomy). 
 After the entire fecal current has been diverted in this mamier, and 
 the lower segment of the bowel thoroughly evacuated and brought 
 into a healthy state by irrigations, direct treatment of the strictures 
 may then be attempted. Posterior prortotonn/ (\erneuil), or incision 
 of the posterior rectal wall, including the sphincters and everything 
 down to the bone, is not to l)e recommended unless the stricture is 
 close to the anus; but it is a good operation in cases where septic proc- 
 titis accomj)anies stricture, as it secures free drainage and relieves 
 the acute symptoms though it does not produce a cure. The hemor- 
 rhage is not alarming and may be controlled by packing gauze 
 around a large rectal tube. It is necessary to continue the passage of 
 bougies subsequently for an indefinite jieriod. In the case of a single 
 high stricture it may be possible to ])erform .s-igiiioido-procto.stoDii/, 
 making an anastomosis by the AIurj)hy button between the sigmoid 
 and the rectum below the stricture; the spur between the strictured 
 and the anastomotic opening may be removed later by Dupuytren's 
 enterotome. In the worst cases of stricture formal excision of the 
 rerfinii, as for malignant disease, is the most satisfactory treatment. 
 
rcMoh's OF 77//<; hkcti'm 913 
 
 Recto-urinary and Recto-genital Fistulae. — Formerly these were 
 frequent results of dlHicuIt ])arturition, following the separation of 
 sloughs caused by pressure of tiie fetal head or by instruments; l)ut 
 ()wiii<^ to improvements in the obstetric art they are now comparatively 
 rare. Occasionally they result from operative injury, or from the 
 rupture of an abscess iuto both the intestinal and genito-urinary tract, 
 or as the result of specific or malignant ulceration. The fistula may 
 connect the intestinal tract with the bladder or urethra (redo-vesical 
 and rcdo-urcthral fiMidw) or with the vagina (recto-vaginal), rarely the 
 uterus {recto-uterine fiduJa) . Vesico-vaginal and vcsico-uterine fistula 
 are results of similar causes and require similar treatment, though 
 the intestinal tract is not involved. The diagnosis is made by obser\'ing 
 the discharge of urine or feces (sometimes only of flatus) through an 
 abnormal channel, and by direct examination with sound or endoscopic 
 instrument (cystoscope, proctoscope) in the bladder or rectum. The 
 only satisfactory treatment is by operation, which consists essentially 
 in dissecting up the borders of the fistula and closing the opening in 
 the wall of each viscus invohed, by means of separate sutures. In 
 the rare cases of recto-uterine or vesico-uterine fistulse hysterectomy 
 may be necessary (Chapter XXIX). 
 
 Tumors of the Rectum and Sigmoid. — Benign tumors are com- 
 paratively rare. Adenoma is the least unusual. It occurs most often 
 in children in the form of redal polypus, and presents symptoms 
 similar to those of hemorrhoids, for which or for prolapsus it is often 
 mistaken, l^sually when the child strains the polypus comes down in 
 reach of the examining finger, or it may prolapse through the anus. 
 Treatment consists in excision after transfixion and ligation of its 
 base. In adults adenoma and papilloma are quite rare growths, and 
 usually are pre-carcinomatous in nature. The tumor is rather soft, 
 seldom is ulcerated, and is freely movable on the underlying rectal 
 wall. It should be freely excised. In the disease known as multiple 
 adenoma the entire colon may be invaded by small polypoid growths, 
 though usually the rectum is the part most involved. The symptoms 
 are persistent bloody diarrhea, with tenesmus, and gradual loss of 
 flesh and strength. If removal of the numerous rectal growths is 
 followed by their persistent recurrence, or if there is a suspicion of 
 malignancy excision of the rectum should be done; or if the entire 
 colon is diseased a false anus may be established in the cecum. 
 
 Carcinoma. — Carcinoma is the most frequent tumor of the rectum. 
 It occurs (1) at the atius (squamous-celled carcinoma), which is rare; 
 (2) just above the sphincters (adeno-carcinoma, often encephaloid), 
 which is not unusual; or (3) above the reach of the examining finger 
 in the upper rectum or pelvic colon, at the level of the promontory of 
 the sacrum (adeno-carcinoma, often scirrhus); in this latter situation 
 about two-thirds of rectal cancers are found. The rectum frequently 
 is invaded by carcinoma originating elsewhere (prostate, cervix uteri). 
 Anal carcinoma causes secondary invasion of the inguinal lymphatics, 
 and clinically resembles epithelioma of the lower lip. True rectal 
 58 
 
014 SURGERY OF THE GASTRO-IXTESTIXAL TRACT 
 
 carcinoma extends in the submucous tissues of the rectal wall rather 
 than directly through it to neighboring structures; and invades the 
 lymph nodes in the hollow of the sacrum, but seldom higher than the 
 promontory of the sacrum. Except in the more highly malignant 
 forms, death is more apt to occur from intestinal obstruction than 
 from local extension or metastasis. 
 
 Symptoms. — The symptoms are hemorrhage (especially in younger 
 patients), alternating diarrhea and constipation, and eventually loss 
 of weight and foul discharge with highly characteristic odor. These 
 symptoms, however, may not appear for months after the development 
 of the tumor, particularly if the latter is high in the rectum. Often 
 the growth is found absolutely inoperable when no symptoms of note 
 have ever existed. 
 
 Diagnosis. — Diagnosis is not difficult at the stage when most 
 patients consult a surgeon. The tumor is irregular in outline, nodular, 
 with raised margins and ulcerated centre; and it is fixed to the bowel 
 wall if not to the surrounding structures. If any doubt exists, a piece 
 should 1)6 excised from the base, for microscopical study. If the 
 growth is too high to be accessible for diagnosis from below, lapar- 
 otomy should be done. 
 
 Treatment. — The first question to decide is whether or not radical 
 operation can be done, and, if this is impossible, whether the establish- 
 ment of a false anus will promote the patient's comfort. The (/rowth 
 may he considered inoperable (1) when the patient's condition forbids 
 an operation with a mortality varying from 10 to 50 per cent.; (2) 
 when the growth is found to be fixed even when examined under 
 anesthesia; or (3) when distinct metastases exist. In such cases 
 palliative treatment aims to reduce -the amount of fecal discharge 
 and decrease its irritating qualities by attention to diet and adminis- 
 tration of intestinal antiseptics; to secure free evacuation of the 
 bowels by gentle purging and by enemas administered if possible by 
 a tube passed above the growth; by local treatment of the ulcerating 
 area by irrigation with permanganate or creolin solution; and finally 
 to keep the patient as comfortable as possible by administering plenty 
 of opium. In rare instances advantage is to be derived from scraping 
 and cauterizing the surface of a cauliflower-like growth. If acute 
 obstruction occurs (it is rare except in carcinoma of the sigmoid) a 
 false anus should be established in the sigmoid, or if the obstruction 
 has existed very long, in the cecum, where the gut is healthier. Unless 
 obstruction is present or death only a matter of a few months, many 
 patients will prefer to suffer rather than be relie^•ed at the expense of 
 an iliac anus; but if the latter is properly constructured and cared for, 
 it produces very little disability, and relieves the patient of untold 
 discomfort by producing latency of rectal symptoms. 
 
 Formation of a False Axus. — Through a left-sided ]^IcBurney 
 incision a loop of sigmoid is drawn out, and its afferent limb drawn 
 taut. If this precaution is neglected prolapse of the descending colon 
 may occur through the false anus. Then the afferent and efferent 
 
C.17i:C7A'O.U.l OF THE RECTUM 
 
 915 
 
 loops are stitclu'd totietluT aloni; tlu'ir iiu'Sfiitfric honlers, for a dis- 
 tance of al)()Ut six inches, so as to form an efficient spur. The loop of 
 bowel is then replaced and sutured in the abdominal wound at the 
 level of the mesentery (Fij;. .S<S5). If the operation is done for acute 
 obstruction a Paul's tube should be fixed in the proximal loop imme- 
 diately. Otherwise it is not necessary to oj)en the gut for several days; 
 the opening is then accomplished i)y a transverse incision. Subsequent 
 treatment involves occasional irrigation of the rectal loop through 
 the false anus, to clear it of discharges (which are much diminished 
 after diversion of the feces from the ulcerating area), and regular daily 
 irrigation of the colon through the upper opening. If the colon is 
 thoroughly flushed out exevy morning, by a pint or more of warm 
 w^ater, and if this injection is retained for about twenty minutes, free 
 evacuation of the bowel is secured by turning face downward and 
 exerting pressure over the cecum. "The patient is then quite com- 
 fortable and clean for the rest of the dav" (Wallis). 
 
 Fig. 885. — Establishment of a permanent false anus by suturing the afferent and 
 efferent loops together "en canon de fusil." A Paul's tube has been tied in each end. 
 
 Radical Operation. — About a week is required to get the intestinal 
 tract in proper shape for operation, and commencing the night before 
 large doses of deodorized tincture of opium should be given (Tuttle). 
 In cases of acute obstruction, or if the sphincters will have to be 
 removed, a preliminary colostomy (as above described) should have 
 been done about two weeks before radical operation. Opportunity 
 should also be taken, when the abdomen is opened, to palpate the 
 liver for metastatic growths. 
 
 1. Where the growth i7n'odes the sphincters, these and the rectum as 
 high as the sacral promontory are removed; and the pelvic end of the 
 rectum is closed and allowed to drain through the p^e^■iously estab- 
 lished iliac anus. The perineal wound is completely closed, with 
 drainage to the hollow of the sacrum. The inguinal lymphatics should 
 be extirpated also. 
 
916 SURGERY OF THE dASTRO-lNTESTINAL TRACT 
 
 2. For a growth just above the anus, in which the sphincters can be 
 preserved, I think the perineal operation as modified by Peck (1909) 
 should be done: The anus is closed by a purse-string suture; then an 
 incision is made from coccyx to rectum and is carried forward on each 
 side of the anus in Y-shape. The coccyx may be excised, but further 
 removal of bone from the sacrum (Kraske, 1885) does not materially 
 facilitate the operation. Both of the levator ani muscles are cut just 
 above the anus; the rectum is separated all around its ciroimiference 
 and is doubly ligated, below the growth, divided between the (linen) 
 ligatures and the cut surfaces are seared with the actual cautery. 
 The peritoneum is then opened, the rectum is freed anteriorly from 
 bladder and prostate, as well as laterally and posteriorly, and is drawn 
 down until an area well above the growth is exposed. It is here again 
 doubly ligated, divided and cauterized, and the tumor is remo^Td. 
 The occluding suture is then removed from the anus, the sphincter is 
 split posteriorly, and the anal mucous membrane is excised. The 
 proximal segment of bowel, still closed by ligature, is then drawn 
 down until it projects well beyond the sphincter, which is sutured 
 around it. The peritoneum and levatores ani are then repaired, the 
 hollow of the sacrum is drained, and the unopened bowel is left pro- 
 truding from the anus. When several days have passed, and granula- 
 tion has begun, so that little fear of infection remains, the redundant 
 bowel (perhaps sloughing in parts) is cut away, and fecal discharge is 
 allowed. Fair sphincter control is preserved; the immediate mortality 
 of such an operation is from 10 to 20 per cent.; and from 20 to 60 per 
 cent, of patients pass the three-year interval without recurrence. 
 
 3. For high rectal carcinoma (all tumors above easy reach of the 
 finger), a combined abdominal and perineal extirpation is the accepted 
 procedure, though the primary mortality even in skilled hands is 
 very high (25 to 50 per cent.), and the permanent cures average 
 only about 16 per cent. This method was first introduced by Maun- 
 sell, and has been popularized in France by Quenu and Hartmann 
 (1897), and in this country by Tuttle and the jNIayos. I believe ^yeir's 
 modification (1901) of the method, in which the sphincter is preserved, 
 is better than the plan of Quenu in which the entire rectum is removed 
 and an iliac anus established, though the latter is the method preferred 
 by Tuttle and ]\Iayo. The surgeon commences by opening the abdo- 
 men in the mid-line and examining the parts. If the tumor is high 
 enough in the sigmoid an ordinary intestinal resection may be done, 
 with end-to-end union, or where possible by lateral anastomosis, which 
 is safer. If the tumor is too low to make this possible, the sigmoid 
 is divided a safe distance ((i inches) above the growth, both ends being 
 closed at once by suture. The meso-rectum is then divided, and, after 
 ligation of the superior hemorrhoidal artery, the rectum and fatty 
 and lymphatic tissue behind it can be stripped oft' the sacrum quickly, 
 and with very little hemorrhage (Fig. 886). The rectum is then doubly 
 clamjjed below the growth, di\'ided, cauterized, and the diseased bowel 
 removed. Next the sigmoid and perhaps the descending colon must 
 
CARCINOMA Ol' Till': HECTUM 
 
 or 
 
 Fig. 8S6. — Abdomino-anal operation for carcinoma of the rectum: the sigmoid has 
 been divided and both ends closed: the rectum has been freed from the hollow of the 
 sacrum. 
 
 Fig. 887. — -Blood-supply of the pelvic colon and rectum: 1, ligature on the superior 
 hemorrhoidal artery; 2, ligature on the inferior mesenteric; 3, ligature on a descending 
 branch of the left colic artery. 
 
918 SURGERY OF THE GASTRO-INTESTIXAL TRACT 
 
 be freed sufficiently to enable the reniaininj^ IxAvel to be brought 
 down to the anus. This is accomplished l)y inobUization of the sigmoid 
 (P. Duval, 1902): the outer leaf of the meso-sigmoid is divided, and 
 the bowel is turned toward the median line by gauze dissection, 
 restoring it to the condition which existed in intra-uterine life. By 
 ligation and section of the sigmoid arteries, and if necessary of the 
 inferior mesenteric itself, close to the root of the meso-sigmoid (Fig. 
 887) sufficient circulation is preserved through the loops of communica- 
 tion from the left colic or e^•en from the middle colic artery (Archibald, 
 1908). Ample slack of sigmoid and descending colon having been 
 secured in this manner, an assistant introduces forceps into the anus 
 from the perineum, and evaginates the lower segment of the rectum; 
 next he pulls down through its lumen the upper segment (sigmoid). 
 The abdominal wound is then closed, after repair of the pelvic peri- 
 toneum. The evaginated rectum and sigmoid are then securely sutured 
 together, and are finally replaced in the pelvis by reducing the evagina- 
 tion. Drainage of the pelvis is pro^•ided by an incision in front of 
 the coccyx. 
 
 If an iliac anus has been made previously, for obstruction or any 
 other reason, it is better to excise the entire rectum, including the 
 sphincters, and to close the perineum. 
 
( IIAI'TKI{ XXIV. 
 
 SURGERY OF THE (JALL BLADDER. LIVER, PAXCREAS, 
 
 AND SPLEEN. 
 
 SURGERY OF THE GALL BLADDER AND BILE DUCTS. 
 
 Infections of the Gall-bladder and Bile-ducts. — It has been shown 
 by Adanii and others that bacteria are constantly being transmitted 
 from tlie intestinal tract throuj^h the portal cirrnlafiou to the lixer. 
 The liver is endowed with antibacterial and antitoxic properties, 
 and under normal conditions the bacteria received in the way described 
 are destroyed in the liver. But if the virulence of the bacteria is 
 increased, or the destructive action of the liver lessened, then such 
 bacteria are excreted from the liver with the bile. The gall-bladder is 
 a suitable place for bacteria to multiply, both from its anatomy, and 
 from certain characteristics which are easily acquired. The bile tends 
 to stagnate in the gall-bladder because of the tortuosity of the cystic 
 duct, because the fundus of the gall-bladder is lower than its outlet, 
 and above all because persons of sedentary habits and those who wear 
 tight corsets do not aid the expulsion of bile from the gall-bladder 
 by active exercise of the diaphragm and abdominal muscles. It is 
 possible also, and not very infrequent, for the gall-bladder to be infected 
 by way of the systemic circulation, through the cystic artery. This is 
 probably the case in typhoid fever, in which disease the infecting 
 bacillus usually can be obtained in pure culture from the gall-bladder. 
 An infection by way of the common hile-duct, ascending from the 
 duodenum is rare. 
 
 If the infection which reaches the gall-bladder either through its 
 contained bile, or through the blood-stream, is very severe, the result- 
 ing changes in the gall-bladder are acute in type. The pathology of 
 acute inflammation of the gall-bladder (cholecystitis) corresponds to 
 that already discussed in connection with the appendix. The walls 
 of the gall-bladder are the seat of round-celled infiltration {phleg- 
 monous inflammation) and this may lead to gangrene or to perforation 
 of the organ. If the infection which reaches the gall-bladder is very 
 mild, a slight catarrhal inflammation occurs, and the interaction of the 
 cholesterin set free in this way with the salts contained in the bile 
 results in the formation of concretions known as gall-stones or biliary 
 calculi. 
 
 Cholecystitis. — The pathogenesis of this condition has been described 
 It is rare except as a complication of gall-stone disease (cholelithiasis, 
 p. 922). Swelling of the spiral folds of mucous membrane lining the 
 
920 SURGERY OF rilE GALL-BLADDER AND BILE-DUCTS 
 
 cystic duct converts the gall-bladder into a closed cavity, and the 
 virulence of the infection is thus increased. If suppuration occurs 
 within the gall-bladder the condition is described as empyema of the 
 gall-bladder. If inflammation spreads to the surrounding peritoneal 
 structures, pericholecystitis is said to exist. Even if the disease is 
 arrested before gangrene or perforation occurs a return to normal 
 does not ensue; pericholecystitis leaves as a legacy pericholecystic 
 adhesions which bind the gall-bladder to the duodenum, pylorus, or 
 omentum, and which may cause kinking of the bile-ducts; while 
 changes in the wall of the gall-bladder and in the cystic duct impair 
 still more its drainage facilities, and stricture or occlusion of the cystic 
 duct may convert the gall-bladder into a permanently closed cavity 
 with contents of very low infectious power, a condition described as 
 hydrops of the gall-bladder. Chronic cholecystitis may occur as a sequel 
 of an acute attack, or if the infection is mild the cholecystitis may be 
 chronic from the beginnins'. It is very rare except in cases of 
 cholelithiasis. 
 
 Symptoms of Acute Cholecystitis. — The patient usually is an adult 
 in early middle life. The affection is rare before thirty years of age, 
 and not very frequent in those over forty years, unless previous attacks 
 have occurred. The attack usually' begins with biliary colic (p, 924) 
 which may be mild or severe. It is a mistake to suppose that biliary 
 colic occurs only when gall-stones are present; as in the case of the 
 appendix, the intestine, and the kidney, the colic is a sign of disordered 
 and violent peristalsis in an effort of the organ to empty itself against 
 resistance. The resistance may be formed by a gall-stone impacted 
 in the neck of the gall-bladder or in one of the ducts, but it often 
 is formed by inflammatory occlusion of the cystic duct, or by an 
 exceedingly viscid and tarry state of the bile which is a frequent 
 condition in the stagnant gall-bladder. In many cases of cholecystitis 
 the pain is not very severe at first, and is felt in the epigastrium, or 
 is diffused through the abdomen; soon, howe^'er, it settles to the gall- 
 bladder region, to the right of the epigastrium or in the right In'po- 
 chondrium. Sometimes referred pain is felt in the right shoulder, 
 under the scapula, or in the right iliac fossa. If the gall-bladder lies 
 low in the abdomen the attack may be confused with appendicitis. 
 Nausea and romititig usually occur, but may be entirely absent. 
 Muscular rigidity and tenderness over the site of the gall-bladder are 
 constant and very valuable signs. The gall-bladder becomes enlarged 
 and usually can be outlined by percussion, and if rigidity and tender- 
 ness are not very great, it may be palpable as a smooth rounded tumor 
 beneath the costal margin continuous with the liver dulness and moving 
 in respiration unless fixed by adhesions from previous disease. Jaundice 
 does not occur in uncomplicated cases of cholecystitis; it implies 
 involvement of the common or hepatic ducts. There usually is fever, 
 but the temperature seldom is very high; there is polynuclear leuko- 
 cytosis. If there is much constitutional reaction, and if the elevation 
 of temperature continues for several days and is high, empyema or 
 
CfWLANGEITIS 921 
 
 threatening gangrene shoultl he suspected. Perforation into the free 
 peritoneal cavity is very rare (Fi^. S()7), and is unusual even into 
 preformed pericliolecystic adhesions. It may he recognized in some 
 ca.ses hy sudden sexere })ain, jxTliaps with symptoms of shock, fall of 
 temperature, rise of jnilse rate, and occasionally hy the sudden dis- 
 appearance of a gall-hhidder tumor previously palpahle. Unless the 
 upper alxlomen is well protected hy adhesions, spreading peritonitis 
 ensues. In the former case a jK'richolecystic, sul)i)hrcnic or, rarely, 
 a perinephric ahscess results. Spontaneous perforation through the 
 ahdominal wall {external biliary fistula), or into the gastro-intestinal 
 tract {infernal biliary fistula) is very rare. 
 
 Diagnosis. — Acute cholecystitis must be distinguished from appen- 
 dicitis (p. S52), gastric or duodenal perforation (p. 807), intestinal 
 obstruction (p. 886), and acute pancreatitis (p. 945). In most cases 
 the correct diagnosis is easy, owing to localization of the signs and 
 symptoms to the gall-bladder region, and the recognition of the 
 enlarged gall-bladder. 
 
 Treatment. — The patient should be treated by rest in bed, in the 
 semi-rccumbent position ; absolute prohibition of food or liquid by the 
 mouth; hot or cold applications to the upper right quadrant of the 
 abdomen; and proctoclysis of saline fluid or tap water. Most mild 
 cases of cholecystitis will subside within a day or two under this 
 treatment. If anything is taken into the stomach peristalsis is 
 aroused, and there is danger of spreading the infection from the gall- 
 bladder to the bile ducts or to the surrounding peritoneal structures. 
 When all acute symptoms have been absent for a day or so, sodium 
 phosphate in hot water may be given by mouth, and then feeding 
 may be cautiously resumed. If the attack does not subside promptly, 
 suggesting the probable occurrence of suppuration within the gall- 
 bladder, the organ should be drained {cholecystostomy, p. 930). 
 
 Cholangeitis. — Cholangeitis, or inflammation of the bile-ducts, is 
 rare except as a complication of gall-stone disease, or as a sequel of 
 catarrhal gastro-duodenitis ("catarrhal jaundice"). In this condition 
 the duodenal mucous membrane around the bile-papilla, and that 
 in the lower end of the common duct, swell up and cause obstruc- 
 tion of the biliary outlet, resulting in the development of jaundice. 
 In many of these cases it is probable that swelling of the head of the 
 pancreas also occurs and compresses the common bile duct, which 
 is known to transverse its substance in two out of three cases. If 
 the attack of jaundice occurs in the young, it usually is due to gastro- 
 duodenal catarrh; jaundice in middle aged or old patients usually 
 is due to gall-stone disease, pancreatitis, or malignancy. In the latter 
 conditions pain is more marked (usually it is entirely absent in catarrhal 
 jaundice); the jaundice is of longer duration (usually it subsides in 
 a week or ten days in cases of gastro-duodenal catarrh); it varies in 
 intensity unless there is obstruction by a malignant growth or pancre- 
 atitis; and attacks of chills and fever are much more common than 
 in attacks of catarrhal jaundice. Chronic catarrhal cholangeitis and 
 
022 SURGERY OF THE GALL-BLADDER AND BILE-DUCTS 
 
 suppurative cholangeitis are very rare except in connection with ,i,^all- 
 btonc disease. 
 
 Treatment. — Cholangeitis due to gastro-duodenal catarrh subsides 
 I)r()ni]>tl}' under ai)propriate medical treatment. Tn other cases the 
 treatment is that of the causati\'e condition. 
 
 Cholelithiasis. — The formation of gall-stones has already been 
 alluded to. TJie chief predisposing condition is stagnation of bile 
 in the gall-bladder. x\s the stagnant gall-bladder is more frequent in 
 women than in men, so is the occurrence of gall-stone disease. The 
 stagnated bile becomes viscid, ropy, and very dark in color. It invites 
 infection, and when such infection occurs, in attenuated form, the 
 union of cholesterin derived from the mucous membrane, with bile 
 salts, results in the formation of concretions (gall-stones). Biliary 
 sand, composed of minute cholesterin crystals, is found not very 
 infrequently in such a gall-bladder, which is otherwise apparently 
 normal. This sand clings to the mucosa of the gall-bladder and can- 
 not be detected with the finger because so fine and so well covered 
 by mucus; it can be seen glistening on the gauze which has wiped the 
 gall-bladder cavity. Such a gall-bladder has been described by Moy- 
 nihan as the ''Cholesterin Gall-bladder," and by Wilson, of the Mayo's 
 clinique, as the "Strawberry Gall-bladder," from the appearance of 
 the minute yellow specks on the inflamed mucous membrane. It is 
 held by Aschoff and Bacmeister (1909) that a concretion composed 
 of pure cholesterin may be formed in the gall-bladder without the 
 presence of bacterial infection; they teach that this stone precedes 
 the formation of all other varieties, which mav be ninnerous. 
 
 Fig. 888. — Radial chijlostorin stcjiic; spontaneous fracture in gall-bladder. Female, 
 aged fifty years, with empyema of gall-bladder. Recovery. (See Fig. 889.) Episcopal 
 Hospital. 
 
 The following varieties of gall-stones may be recognized: (1) The 
 pure cholesterin stone (Figs. 888 and 889) usually is of fairly large 
 size and oval in shape; it is soft when first formed but becomes hard 
 and brittle on drying; is white, yellowish, or brownish black on the 
 surface, but white and crystalline on section. It is not stratified, but 
 is composed of radiating crystals around a comparatively soft centre, 
 which in the dried specimen may be hollow. (2) Laminated cholesterin 
 stone. Laminations indicate that secondary deposits of bile salts have 
 occurred around the primary radial cholesterin stone, (o) The common 
 gall-stones, or mixed cholesterin calculi, vary greatly in number and size 
 
CIIOLELITIIIASIS 
 
 923 
 
 iiiui usiuillv arc fiu-eted; the surfacr color usually is ycllowisli. They 
 arc all formed at or about the same time, aud arc pressed nito their 
 faceted siiape while still soft (FiK^ Nf><>). (^ Mixed bilirubin-calcium 
 stones are less usual, generally occur siugly, or in groups of three (.r 
 four, ou sectiou show conccutric layers of dark reddish-hnnvu materiaj; 
 and'ou drviim- usually coutract witli the formation of fissures. (5) 
 Pure bilirubin-calcium stones also occur, as do certain still rarer forms. 
 
 S.imc stone as 
 tal. 
 
 Yu: .SS9.— Cholest.'i-in fiall-stone, with polishofl facot at eac-li end. ^amo s 
 Fig. 88S, aftor fraKmcnts liad Ix-cn sluod toKothcr. iMMscopal Ho.spit 
 
 Gall-stones are the result of previous disease in the gall-bladder, and 
 may form so silently- that little indication of their presence is given 
 until some acute infection arises, causing acute calculous cholecystitis, 
 or cholangeitis. Thev are formed in the gall-bladder, not in the liver 
 or bile ducts, and so long as they remain in a gall-bladder free from 
 infection mav produce no noteworthy symptoms. This state is 
 described as "simple Cholelithiasis. But the presence of the concre- 
 
 FiG 890.— Common gall-stones, from a gall-bladder removed for acute calculous 
 cholecystitis, in a woman, aged thirty-seven years. Dyspepsia for years and much 
 bek'hiiig aft Jr meals. Wakened one midnight by epigastric pain ; two days later enlarged 
 gall-bladder palpated; admitted for operation on third day; cholecystectomy; recovery. 
 Episcopal Hospital. 
 
 tions predisposes the gall-bladder to infection, and if one or more of 
 the calculi wander from the gall-bladder and enter the cystic or the 
 common duct, very serious symptoms may arise. At operation these 
 ducts are found to' have been invaded by one or more calculi in nearly 
 40 per cent, of cases (Deaver and iVshhurst). 
 
 Simple CholeUthiasis.— This has been defined above. The gall- 
 stones ha^•e remained quiescent in the gall-bladder since the time of 
 their first formation, perhaps many years previously. The symp- 
 
924 SURGERY OF THE GALL-BLADDER AND BILE-DUCTS 
 
 toms are due to a chronic catarrhal cholecysiitls, and the pathological 
 changes in the gall-bladder are not very marked. The bile is thick 
 and tarry, but so long as no acute infection occurs the patients are 
 not much troubled. But certain ssonptoms are present by which the 
 disease may be recognized, and they can be discovered by studying 
 carefully the history of the case. These symptoms usually are con- 
 sidered gastric in origin, and the patient attributes to "indigestion" 
 fleeting attacks of pain, dull, boring, or grasping in character, which 
 occur in the epigastrium, but which are irregular in their occurrence 
 and are dependent on no recognized factor. Pylorospasm may occur, 
 but vomiting is rare, as is acute pain. If slight pressure over the gall- 
 bladder region relieves the discomfort it is probable that perichole- 
 cystic adhesions are present. In cases of simple cholelithiasis there 
 may be tenderness over the gall-bladder, and various special points 
 of tenderness (corresponding to McBurney's point in appendicitisj 
 ha\'e been described, but I have not found them of practical signifi- 
 cance. With the patient sitting and leaning forward, the surgeon 
 may stand behind him, with one hand hooked under each costal margin 
 at the ninth costal cartilage. If at the end of deep inspiration, which 
 forces the gall-bladder against the finger tips, the patient experiences 
 a sudden severe pain, it is the opinion of some that gall-stones are 
 present. This is known as ^Murphy's test for cholelithiasis; I have 
 repeatedly found it unreliable. With the patient recumbent, the right 
 loin may be supported with tlie left hand, while with the finger tips 
 of the right the gall-bladder is palpated beneath the costal margin. 
 Sometimes at the end of deep inspiration it can be felt and if diseased 
 usually is tender and painful. There is also very commonly a tender 
 spot to the right of the twelfth dorsal vertebra (Boas's area). 
 
 Biliary Colic. — Biliary colic usually has occurred once or oftener 
 before patients come to the surgeon for operation. As stated already, 
 it may occur where no calculi are present. In the mildest cases the 
 pain may be fleeting, and the patient may forget its occurrence unless 
 closely questioned, especially as the earlier attacks of colic usually 
 cause pain in the mid-epigastrium and not over the gall-bladder. In 
 other cases, however, the initial attack is severe. A man, believing 
 himself to be in the enjoyment of excellent health, except for slight 
 gastric symptoms which have never incommoded him, may suddenly 
 have a dreadful cramp in his upper abdomen; he bends forward press- 
 ing his hands or the back of a chair into his belh'; breaks out in a 
 cold sweat; becomes deathly pale and feels faint; is nauseated; and 
 sometimes his distress is relieved by vomiting. Or he may writhe 
 around his bed, or even on the floor in utmost agony. When the 
 obstruction is relieved by the calculus falling back into the gall-bladder 
 or by the cystic duct becoming patulous, pain ceases instantly. If 
 obstruction continues pain does not vanish, but continues for hours 
 or days, but not so intense as at first. The pain now shifts to the 
 gall-bladder region, and may be referred to the back or shoulder 
 through filaments of the fourth cervical nerve, from wliich the phrenic 
 
MICUA I'h'l) <;.\LL-ST()NES 
 
 wi:) 
 
 is ck'rhod. W lien tliore is fomplete obstruction of the cystic duct, 
 colicky pain quickly disappears. 
 
 Acute Calculous Cholecystitis is a fn^qnent occurrence in cases of 
 sinii)lc cliolelitliiasis. The symptoms do not dili'er from those of non- 
 calculous cholecystitis (p. 920), and it is largely on the recurrence of 
 synij)tonis that the diagnosis of gall-stones is based. 
 
 Migrated Gall-stones. -In many cases of cholelithiasis it is possible 
 to determine whether the calculi remain in the gall-bladder or have 
 escaped into tlie bile ducts, and especially whether or not the common 
 duct is involved. As only a few of the calculi usually leave the gall- 
 bladder the clinical picture maj' be somewhat confusing. 
 
 Stone in the Cystic Duct. — As soon as a stone enters the duct, typical 
 gall-stone colic results and paroxysms of pain recur until the stone 
 either pusses through the duct, 
 returns to the gall-bladder, or is 
 arrested permanently in the duct. 
 If in the latter case obstruction 
 is complete, colic gradually ceases, 
 and usually the gall-bladder be- 
 comes distended and enlarged, 
 causing at first empyema, and later, 
 if the infection becomes attenuated, 
 hydrops. In many cases, however, 
 when a stone is lodged in the cystic 
 duct, it forms a diverticulum for 
 itself and bile can still enter and 
 leave the gall-bladder. Perforation 
 incases of cholelithias is occurs usu- 
 alh' at or near the origin of the 
 cystic duct; while in non-calculous 
 cholecystitis it occurs oftenest at 
 the fundus of the gall-bladder. 
 
 Stone in the Common Duct. — It is 
 rare for a stone to pass completely 
 through the choledochus. The larger 
 stones are arrested in its supra- 
 duodenal portion, and the smaller 
 in its retroduodenal or in the 
 ampulla of Vater. Complete ob- 
 struction, when it occurs, seldom 
 lasts more than a week or ten days, 
 the acute attack then subsiding 
 
 and perhaps not recurring again for weeks or months. Each attack 
 of colic is characterized by jaundice, fever, and marked constitutional 
 disturbance. These are absent in simple biliary colic. They are due 
 to recurrent attacks of cholangeitis, causing temporary complete 
 occlusion of the choledochus with damming up of bile and pus, xery 
 seriously threatening the integrity of the liver, and frequently bringing 
 
 Fig. 891. — Sites 6! lodgement of nii- 
 firated biliary calculi: in the neck of 
 the gall-bladder; in the cystic duct; in 
 the hepatic duct; in the common duct 
 (supra-duodenal, retro-duodenal, or pan- 
 creatic portion), or at the papilla of 
 Vater. 
 
92G SURGERY OF THE GALL-BLADDER AND BILE-DUCTS 
 
 the patient to death's door. The calculus does not float around free 
 in the bile-duct, acting as a ball-valve, as described by Fenger (1696): 
 at operation it usually is found firmly fixed, sometimes in a divertic- 
 ulum. The fever rises abruptly to 104° F. or higher, and falls again 
 as ra])idly to normal or subnormal. It is known as "Charcot's inter- 
 mittent fever," ailtl Moynihan describes the temperature record as 
 a "steeple" chart, from its sudden variations. The jaundice also 
 is intermittent, or at least lessens from time to time, and stercobilin 
 is never very long absent from the feces. Persistence of jaundice, 
 with its accompanying constitutional condition, known as cholemia, 
 is a verj' dangerous feature, and the tendency to hemorrhage becomes 
 very marked, owing to the prolongation in the clotting time o^' the 
 blood. 
 
 When there is calculous obstruction of the common duct, the gall- 
 bladder is found to be contracted in 80 per cent, of cases; and in 90 
 per cent, of cases where the gall-bladder is enlarged, the obstruction 
 is due to causes other than stone, usually malignant disease. This 
 is known as Courvoisier's Law (1890). The explanation is that the 
 gall-bladder has been diseased so long before the stones migrate into 
 the common duct, and has become so contracted and thickened as a 
 result of disease, that it can no longer dilate under the influence of 
 back pressure. 
 
 Stone in the Hepatic Duct. — Calculi are found in the hepatic duct 
 only when they have floated upward from the common duct, or when, 
 the common duct being already full of stones, others descending from 
 the gall-bladder have to pass into the hepaticus. Gall-stones (except 
 biliary sand) are not formed in the liver except when the choledochus 
 and common hepatic duct are already filled. The symptoms of stone 
 in the hepatic duct cannot be distinguished from those due to common 
 duct calculus. 
 
 Treatment of Cholelithiasis. — In cases of simple choleUthiasis operati\'e 
 treatment should be urged, unless any operation is contraindicated 
 by extreme age, or by visceral disease. There is no medicine which 
 will cause the solution of the stones, though charlatans often deceive 
 patients by administering olive oil in large quantities and telling them 
 that the fecal concretions so produced are the biliary calculi. But it 
 is possible by strict medical treatment, such as diet, hygiene, etc., to 
 keep the disease latent for many years in some cases; and most patients 
 who can afford such a life will be satisfied to adopt this procedure 
 rather than operation. But they should be informed that, as Mayo 
 writes, the danger of the de\elopment of carcinoma in such a gall- 
 bladder (see p. 942) is five times as great as is the mortality following 
 operation for the relief of simple gall-stone disease, when performed 
 by a competent surgeon. And Kehr says "the slight dangers of early 
 operation stand in no sort of a relation with the great dangers of the 
 disease itself; even the latent cholelithiasis we should always regard 
 with suspicious eyes, for the quiet work of gall-stones is often the most 
 destructive. In jnalignancy and insidiousness," concludes Kehr, "??o 
 
T UK ATM EST OF CHOLELITHIASIS 927 
 
 (li,sr(tsc of iinin com/xin's irllli cholcliihldsi.s." It', alter their attendant 
 has stated the tacts ot" the case, the patients still will not he operated 
 on, that is their own look-ont. The mortality followinfi; oj)eration in 
 these simple cases, in competent hands, is less than 5 per cent. 
 
 The proper operation in the ^"ast majority of cases of sinij)Ie chole- 
 lithiasis is removal of tlie calculi and drainaf^e of the pill-bladder 
 {cholecysiostomy, p. 930) ; only if the gall-hladder is so altered by dis- 
 ease as to be functionally useless, is it desirable to remove it {chole- 
 cy.stiriomii, ]). \Y.\\). ]iecurrence of gall-stones after cholecystostomy 
 is very unusual, and generally the stones that are found subsequently 
 are not newly formed, but were overlooked at the first operation. 
 The mortality of cholecystectomy is slightly higher than that of simple 
 drainage, but in cases of acute calculous cholecystitis it is to be j)referred, 
 as also in every case where the gdll-hhiddcr is- >nurh cotitracied or thickened. 
 and in cases of the '' cholesterin (jaU-hladder." Cholecystectomy is 
 also to 1)6 done in cases of obstruction of the cystic duct by a calculus, 
 since stricture, with resulting hydrops, is the almost inevitable result 
 of removal of such a stone. In cases of hydrops and gangrene always, 
 and in most cases of empyema or perforation remo\al of the gall-bladder 
 is indicated.' 
 
 In cases of stone in the common duct the patients may come under 
 observation either during an attack of obstruction with cholangeitis, 
 or during a free interval. In the latter contingency there is no need 
 to ])ostpone operation, and removal of the stone or stones should be 
 undertaken. In the presence of acute complete obstruction of the 
 common duct, however, it is the teaching of nearly all surgeons that 
 operation should be dela^'ed until under medical treatment (as for 
 acute cholecystitis, p. 921) complete obstruction has subsided. Deaver 
 and Ashhurst contend, on the other hand, that by waiting the patient 
 runs the risk of cholangeitis, cholemia, with the gravest form of sepsis; 
 not to mention perforation of the common duct or the formation of 
 almost inoperable adhesions, or the indefinite persistence of chronic 
 jaundice with its dangerous hemorrhagic tendencies. The fact that 
 the mortality of operations during persistence of complete obstruction 
 is \ery much higher than that of inter\-al operations is not a valid 
 argument against immediate operation, since the c(uestion is not 
 the death rate from operation, but the death rate from the disease. 
 Dea^■er says "while many times there has been cause to regret not 
 operating during the stage of acute obstruction, never yet has there 
 been cause to regret prompt relief of the obstruction by operation." 
 
 The operation consists in removal of the stones in the common duct 
 (by choledochotomy, p. 932), thorough exploration of the common 
 and hepatic as well as the cystic duct, and drainage of the common 
 
 ' Individuals! known as "typhoid carriers," in whom the gall-bladder acts as a 
 store-house for typhoid bacilli which are discharged with the feces, and who often 
 cause epidemics of typhoid fever, may be surely relieved of their infecting quali- 
 ties by removal of the gall-bladder. No medicines are of any value, and anti- 
 typhoid vaccination has been tried without success. 
 
92S OPERATIONS ON THE GALL-BLADDER AND BILE-DUCTS 
 
 duct and the gall-bladder by separate tubes. Occasionally the gall- 
 bladder has to be removed. 
 
 Obstruction of the Common Duct may result from stricture, the 
 result of previous operative interference, or from tumor formation, 
 as well as from lodgement of calculi. If the stricture is benign in nature, 
 the bile should be short-circuited into the intestinal tract by an anas- 
 tomosis between the gall-bladder and duodenum or stomach. If the 
 gall-bladder has been removed, and cholecystenterostomy is therefore 
 impossible, an anastomosis will have to be made between the dilated 
 duct above the obstruction and the intestine {choledocho-enterostomy , 
 hepatico-enierostomy) . If the obstruction is due to malignant disease, 
 no operation beyond exploration should be done, unless the disease 
 can be completely removed. Carcinoma of the gall-bladder and bile- 
 ducts is considered at p. 942. 
 
 In cases of postoperative external biliary fistula the gall-bladder 
 should be removed, if the common duct is patent; if the gall-bladder 
 has already been removed there is almost certainly obstruction of the 
 common duct. In either case obstruction of the common duct is to 
 be treated as above indicated. 
 
 OPERATIONS ON THE GALL BLADDER AND BILE DUCTS. 
 
 The deeper structures may be made much more accessible by 
 placing a sand-pillow (about four to six inches in thickness) beneath 
 the patient's spine, at the level of the liver, thus throwing the upper 
 abdomen forward, and allowing the intestines to fall toward the 
 pelvis. The head and shoulders should be suitably supported so as to 
 facilitate administration of the anesthetic. In very difficult cases the 
 foot of the table may be lov,ered (reversed Trendelenburg posture) 
 as originally advised by Elliot, of Boston, who introduced in 1895 the 
 position above described. 
 
 The incision in common use for biliary operations is that known as 
 Mayo Robsons (Fig. (S93) ; in simple cases only the longitudinal incision 
 through the rectus muscle is necessary. In cases which promise to be 
 very difficult Czerny's W inkeJschnitt (1S92) is to be preferred: this 
 runs from 5 to 7 cm. in the mid-line, above the umbilicus, and bends 
 to the right just below the umbilicus, cutting the rectus transversely. 
 Kehr has abandoned (1912) his original bayonet incision (Welleti- 
 schnitt) and now employs an angular incision somewhat like Czerny's. 
 Sprengel's transverse incision which divides the right rectus muscle 
 directly across at whatever level seems desirable, and which may be 
 extended in the same direction if necessary, is gaining favor in Europe; 
 Gosset in France and Korte in Germany have adopted it. Before 
 suturing any of these incisions, the support should be removed from 
 beneath the patient's spine. 
 
 After the abdomen has been opened the parts concerned in the opera- 
 tion must be well protected by gauze pads. One is placed in the sub- 
 hepatic space or right kidney pouch, a second presses the stomach 
 
AliDOMlSM. ISCISIOSS 
 
 929 
 
 
 out of the way toward the left, a third is placed oxer the ^astro- 
 Iu'i)atic omentum just below the liver, and a fourth is packed down 
 toward tlie eeeum. Sometimes another pad is placed between the 
 rijjht lobe of tlie liver and the 
 dia])hrajj;ni. Tn many o|)crations 
 it is possible to draw the lixcr, 
 and with it the gall-bhulder, 
 partly out of the wound. If the 
 h)wer border of the liver is drawn 
 slightly downward and then 
 lifted upward into the abdomi- 
 nal incision, sliji^htl}' rotating 
 the organ so as to turn its in- 
 ferior surface toward the ])a- 
 tient's left, it fully exposes the 
 gall-bladder and brings the cystic 
 and common ducts very near the 
 surface. In this way the cystic 
 duct forms almost a straight line 
 with the common duct, which 
 is therefore more easily found. 
 An assistant should hold the liver 
 in this position with the aid of 
 gauze sponges. Too much force 
 must not be used. I have torn 
 the liver in trying to deliver it. 
 
 '^ 
 
 \ 
 
 Fig. 892. — Mayo Robson's and Czerny's 
 incisions for operations on the biliary tract. 
 (See text.) 
 
 o 
 
 Fig. N'J.3. — Majo Robsou incision for cliolocystostomy. Eijiseupal Hospital. 
 59 
 
930 OPERATIONS ON THE GALL-BLADDER AND BILE-DUCTS 
 
 Cholecystendysis is the name given to the operation in which after 
 ojxMilng the gall-hhidrler for removal of calcnli, it is at once sutured 
 and the abdominal wound closed without drainage. The operation is 
 scarcely e\er done at present, and is not to be commended. A gall- 
 bladder which needs to be opened needs also to be drained. 
 
 Cholecystotomy and Cholecystostomy. — The former term implies 
 merely oi)eniiig the gall-bladder, while the latter indicates that it is 
 left open for the purpose of drainage. The terms often are used 
 synonomously. The gall-bladder is exposed and isolated by gauze 
 packs. If distended the contained fluid is remo\'ed by trocar and 
 cannula, taking care to prevent contamination of surrounding struc- 
 tures or the abdominal wound. The gall-bladder is then pulled into 
 the wound and opened at .the fundus with scissors, and the finger is 
 introduced for exploration. 
 
 Gall-stones are removed with scoop, forceps, or spoon. Thick and 
 tarry bile is wiped out, and the surgeon makes sure that no calculi 
 
 remain in the neck of the gall-blad- 
 der or the cystic duct by palpation 
 with a finger on the outside and 
 a sound in the lumen of the duct. 
 Unless the patient's condition for- 
 bids, the surgeon should then explore 
 the common duct and the head of 
 the pancreas, while the gall-bladder 
 is temporarily plugged with gauze. 
 These manipulations are described 
 at p. 932 (Choledochotomy). When 
 it is certain that no stones remain, 
 a purse-string suture of catgut is 
 inserted in the fundus of the gall- 
 bladder about an inch from the 
 opening. A drainage tube open on 
 the side as well as at the end, or 
 cut in fish-tail fashion^ is passed into 
 the gall-bladder for about an inch, 
 and is stitched to the gall-bladder 
 with two or more catgut sutures. 
 The tube is then pushed into the 
 gall-bladder, inverting its edges 
 around the tube, and the purse- 
 string suture is pulled taut and tied. With this valve-like closure of the 
 opening the biliary fistula does not remain open long after the tube 
 is removed. If the gall-bladder cannot be inverted in this manner the 
 opening should be sutured tightly around the tube, and in such cases 
 or whenever there is a possibility of leakage around the tube it is 
 
 '■ It is convenient to have this tube wrapped in gauze and the gauze again- sur- 
 rounded by rubber dam, so that the sutures holding it to the gall-bh^dder will not 
 tear out. 
 
 Fig. 894. — Cholecystostomy: the gall- 
 bladder tube is surrounded with gauze 
 from a cigarette drain. (Deaver and 
 Ashhurst.) 
 
CHOLECYSTOSTO.M Y AM) ( 'IIOLFA ' YSTI'U TOM Y 
 
 \YM 
 
 safer to insert alst) a small cigarette drain Ix-sidc the gall-bladder 
 (Fig. S()4). 'I'lie gauze pads are tlieii removed and the alxlominal 
 \v(»imd is closed around the drainage. The tube in the gall-hladder 
 remains until it I'omes away of itself, whieh is usu.dly about the end 
 of the second week. The fistula in sueh cases ceases to discharge bile 
 \'ery soon after the tube is removed. When prolonged drdlnnge is 
 desired, as in cases of cholangeitis, pancreatic lymphangeitis, etc., 
 the gall-bladder should not be iincrted around the tube, but should 
 be closed tightly around it without inversion of its wall; then the 
 gall-bladder should be sutured to the parietal peritoneum, or even to 
 the anterior sheath of the rectus muscle; and biliary drainage should 
 j)ersist for from four to six weeks at the least. In some cases of pan- 
 creatic disease many months are required before it will be safe to 
 allow the fistula to close. 
 
 Fig. 895. — Cholecystectomy: the cy.stic duct and the cystic vessels have been cUiiiipcd 
 and Hgated, and the gall-bladder is being enucleated from its bed under the liver. The 
 method of suturing the peritoneal folds is indicated. (Deaver and Ashhurst.) 
 
 Cholecystectomy. — After exposure and isolation of the parts in 
 the usual way, the cystic duct is identified, and the peritoneum over- 
 lying it is incised, and is separated from the cystic duct by gauze 
 dissection until the common duct is reached. The cystic duct is then 
 
932 OPERATIONS ON THE GALL-BLADDER AND JilLE-DUCTS 
 
 grasped with two hemostatic forceps and is divided l^etween them. 
 The cystic artery and vein which He above and to the inner side of the 
 duct are then clamped with two hemostats and divided l^etween. 
 The cystic vessels may be ligated now or later. The gall-bladder 
 is then enucleated from its attachments to the liver, leaving a peri- 
 toneal fold on each side (Fig. 895). When the gall-bladder has been 
 removed these peritoneal folds are sutured together; but if there is 
 much bleeding from the denuded liver surface, or in cases of marked 
 infection, it is safer to put a cigarette drain in the bed of the gall- 
 bladder and suture the peritoneal folds over it. 
 
 If on opening the abdomen the surgeon encounters very dense 
 adhesions, it may not be practicable to proceed as above indicated. 
 In such cases Terrier's operation (1905) is to be preferred: the anterior 
 margin of the liver is identified, and the fundus of the gall-bladder 
 found. The gall-bladder is opened at its fundus and its lower wall is 
 cut open little by little by snipping with fine scissors. This incision 
 is continued into and through the cysticus, right down to the chole- 
 dochus. The splitting of the cystic duct is the most difficult part of 
 the operation, because it cannot be distinguished from the outside, 
 on account of adhesions, and it is only by following its lumen, as 
 one follows the strictured lumen of the urethra in external perineal 
 urethrotomy without a guide, that the choledochus can be reached. 
 
 Before concluding the operation of cholecystectomy, the common 
 and hepatic ducts should be sounded, through the stump of the cystic 
 duct, to make certain that no calculi have been overlooked. A drain- 
 age tube is then passed into the stump of the cysticus, and up the 
 hepaticus for about 1 cm., and is stitched in position with No. 
 chromic catgut. The subhepatic space should also be drained b}' a 
 tube, and these two tubes must be carefully distinguished (by color, 
 by insertion of two safety pins instead of one, or in some other way), 
 so that no subsequent confusion can arise. The abdominal wound 
 is then closed around the drainage. The tube to the subhepatic space 
 may be removed on the second or third day, but that which drains 
 the hepaticus should be allowed to remain at least for two weeks. If 
 there has been much hemorrhage or escape of bile into the subhepatic 
 space it is safer to use a glass tube for drainage of this region. This 
 tube is replaced by a rubber tube within a few days, and the subse- 
 quent treatment conducted as when a glass tube has been used to 
 drain the pelvis (p. S62). 
 
 Choledochotomy and Choledochostomy are employed interchange- 
 ably as are the corresponding terms relating to the gall-bladder, since 
 at present almost every operation involving an incision into the chole- 
 dochus is supplemented by drainage of that structure. When the 
 gall-bladder is present it serves as a guide to the common duct, which 
 is brought into the wound, when possible, by the method noted at 
 p. 929, after the gall-bladder has been opened and cleared of stones 
 as previously described. The common duct often is much dilated 
 and it may be difficult to distinguish it from the portal vein. For 
 
CllOLKDOClKnOMY 933 
 
 this purpose a liypodermic iuhmIIc may he used, as advised by Terrier 
 and l>y 1 )eaver. The index fiiijj;cr is passed into the foramen of \Vinsh)\v, 
 while the thumb is plaeed on the free horder of the j^astrohepatic 
 omentum and the supraduodenal portion of the choledoehus is pal- 
 pated. If a stone is found it searcely ever is j)ossihle to push it haek 
 through the eystieus into the irall-hladder, l)ut sometimes the seoop 
 or forceps may be passed down from the gall-bladder through the 
 eystieus for removal of the stone. In most cases, however, it is neces- 
 sary to incise the duct over the stone to extract it. This incision is 
 made in the long axis of the duct and of convenient length. If the 
 duct is large enough the finger makes the best probe to search for other 
 stones. Any stones detected bv finger or scoop or sound, should l)e 
 pushed toward the opening in the choledoehus; if impacted in the 
 retroduodenal portion of the duct a stone may be crushed between the 
 fingers or broken up by the scoop, and the fragments extracted from 
 the incision in the supraduodenal portion or pushed into the duodenum 
 through the ampulla of \'ater. As a last resort relroduodenal chole- 
 dochofomy may be necessary; or if a calculus is impacted in the lower 
 end of the common duct very close to the duodenum, transduodenal 
 choledochotomy may be necessary. These operations are described 
 below. 
 
 "When all stones have been removed, the common duct is drained 
 by passing a rubber tube large enough to fill its lumen up toward 
 the hepatic duct for 1 to 2 cm. (Hepaticus drainage, Kehr's operation.) 
 The tube is fixed in the common duct, as described in connection 
 with cholecystectomy; and the gall-bladder is drained by a separate 
 tube. (If cholecystectomv is necessarv the stump of the eystieus may 
 be closed with suture). The operation is concluded by drainage of 
 the subhepatic space, as after cholecystectomy. 
 
 In cases ivhere the gall-bladder is absent, choledochotomy may be 
 a very diflficult operation if many adhesions are present, as there is 
 no guide to its location. In such cases Desjardins recommends that 
 the surgeon commence by exposing the retroduodenal portion of the 
 choledoehus by mobilization of the duodenum, as described below. 
 Or the surgeon may open the duodenum and identify the choledoehus 
 by retrograde catheterism through the ampulla of Vater. I believe 
 the former method is preferable. 
 
 Retroduodenal Choledochotomy. — If an incision is made through the 
 parietal peritoneum on the right of the descending duodenum, this 
 coil of intestine may be separated by blunt dissection from the posterior 
 abdominal wall, and restored to the condition it occupied in fetal life. 
 By turning the duodenal loop to the left {mobilization of the duodenum, 
 Jourdan, 1895) the head of the pancreas and the retroduodenal por- 
 tion of the common duct are brought into view (Fig. 896), and an 
 impacted calculus may be removed by direct incision (Fig. 897) . As 
 in most cases in which this operation is necessary the supraduodenal 
 portion of the choledoehus has already been opened, this may be used 
 for drainage, and the incision in its retroduodenal portion sutured. It 
 
1»;U OI'EHATIOXS OS THE CALL^BLADDER AXD JilLE-DUCTS 
 
 is wise, h()\ve\er, to k>a\'e a drain in tlic retroduodenal s])ac(', for fear 
 of leakage. 
 
 Transduodenal Choledochotomy (McBurney, ISOI) is ap])licable to a 
 calculus iin])acted in the aniijulla of Vater or very close to the duo- 
 denal wall. The duodenum is opened through its anterior wall, and 
 the bile pai)illa identified. If a calculus is caught in the ampulla 
 it usually is possible to extract it by dilating or incising the paj)illa. 
 
 Fig. 896. — Retroduodenal choledochot- 
 omy: after mobilization of the duodenum, 
 a stone is exposed at the site of obstruc- 
 tion to the sound. (Deaver and Ashhurst.) 
 
 Fig 897. — Retroduodenal choledochot- 
 omy: the choledochus is incised over the 
 impacted calculus. (Deaver and Ash- 
 hurst.) 
 
 If it is impacted in the common duct just outside the duodenal wall, 
 it is necessary to inci.se also the posterior wall of the duodenum over 
 the calculus, and then to open the choledochus and remo\e the stone. 
 The opening in the choledochus is then sutured to the incision in the 
 posterior duodenal wall, to ensure adequate drainage of the chole- 
 dochus; this is Kocher's operation of diiodeno-choledochostomy (1895). 
 The incision in the anterior wall of the duodenum is then sutured as 
 any intestinal wound, and the abdominal incision is closed in the 
 usual way. 
 
 Cholecystenterostomy. — The anastomosis may be made with the 
 duodenum (cholecysto-duodenostomy) or with the stomach (chole- 
 cysto-gastrostomy). A lateral anastomosis, about an inch long, by 
 suture (p. 834), is the best method, but if it is impossible to apply 
 rubber-covered clamps to prevent fecal extravasation during the 
 operation, a small sized Murphy button may be used for the anasto- 
 mosis. 
 
A XO.M AUKS or SIIAI'E AM) roSIT/OX 
 
 935 
 
 SURGERY OF THE LIVER. 
 
 Anomalies of Shape and Position. Kx(ri)t in rare cases of con- 
 genital, <liai)lira<:niatic, or unil)ili(;il hernia the position of the Hver 
 seldom is altered unless hepatoptosis (fallinj^; of the liver) exists in con- 
 nection with visceroptosis (p. 898). Apart from rather vague pains 
 hei)atoptosis produces no characteristic symptoms and the diagnosis 
 nnist he made hy recognition of tiie li^■er in its abnormal j)osition. 
 Usually it descends somewhat toward the median line, and is recognized 
 as a large tumor to the right of the umbilicus of the size and con- 
 sistency of the liver; often a notch can be felt. When displaced 
 there is resonance over the normal site of the liver dulness, and 
 pulmonary resonance and intestinal tympany may merge. It is 
 distinguished from a movable or enlarged kidney by the absence of 
 urinary symptoms, by the fact that the liver moves in respiration, 
 while the kidney does not, and that it lies in front of the colon, not 
 l)ehind it. 
 
 Treatment. — Treatment should consist in reposition of the liver, 
 when this is possible, with the patient recumbent, and the applica- 
 tion of an abdominal belt as in cases of pendulous abdomen fFig. 
 <S7o). If palliati^"e treatment proves ineffective, the abdomen may 
 be opened and the anterior margin of the liver stitched to the costal 
 border, with mattress sutures of heavy chromic catgut. 
 
 Changes in the Shape of the Liver usually are acquired, and are of two 
 main varieties. In one, the so-called corset liver (Fig. S9S), the plastic 
 liver has become indented 
 by compression through the 
 costal margin. This tends to 
 distort the cystic duct, caus- 
 ing stagnation of bile, with 
 its consequences already dis- 
 cussed (p. 922). In the other 
 form the anterior margin of 
 the liver is drawn down in a 
 tongue - shaped protrusion, 
 known as linguifonn or Riedel's 
 lobe (1888). Usually disease 
 of the biliary tract exists and 
 has produced the deformity 
 by gradual traction from ad- 
 hesions or the weight of an 
 enlarged gall-bladder. Treat- 
 ment involves operative cure 
 of the biliary lesion, after 
 which the enlarged lobe usu- 
 ally shrinks (Terrier) ; in rare instances amputation of the lobe may 
 be desirable. 
 
 y 
 
 Fig. ^9(S. — Corset livtr, from a patient aged 
 fifty-seven jears. Death from perforation of a 
 malignant ulcer of the stomach. (.See Fig. 849.) 
 Episcopal Hospital. (Deaver and Ashhurst.) 
 
930 SURGERY OF THE LIVER 
 
 Suppurative Hepatitis. — There are three main \arieties of siippiira- 
 tiou wliicli occur in tlie Hver: (1) Abscess the result of trauma; (2j 
 pyemic or embohc abscess; and (3) tropical or amebic abscess. 
 
 1. Traumatic Abscess is rare; it may occur as the result of a pene- 
 trating wound, or from secondary infection (through tjie blood or 
 bile) of a hematoma which has resulted from subcapsular rupture 
 (p. 841), usually is single and may be of large size. The diagnosis 
 depends on the history of the case, and development of symp- 
 toms of pus formation; and the treatment is the same as for tropical 
 abscess. 
 
 2. Pyemic or Embolic Abscess, when of surgical interest, almost 
 invariably is the result (»f infection through the portal circulation, and 
 is termed suppurative pylephlebitis. Especially frequent as causes 
 are appendicitis and typhoid fever, but any infection in the distribu- 
 tion of the portal vein may be the cause; and cases of suppurative 
 cholangeitis involving the finer intrahepatic bile-ducts often cannot 
 be distinguished either during life or at autopsy from cases of suppu- 
 rative hepatitis caused by hematogenous infection. When occurring 
 from appendicitis or other acute infection the symptoms (pain, high 
 but irregular fever, chills, sweats, tenderness, and enlargement of the 
 liver, sometimes jaundice) usually develop within a week or two of 
 the primary affection. In such cases the liver is riddled with abscesses 
 of various size, and operative treatment is out of the question. Every 
 such case is fatal. When resulting from t\'phoid fever, however, and, 
 according to Quenu and Mathieu (1911), occasionally as the result 
 of appendicitis, the symptoms do not appear until convalescence is 
 established. The average fever-free interval in typhoid fever, according 
 to Melchior (1910), is fourteen days. Such cases resemble somewhat 
 amebic abscess, and treatment is the same. 
 
 3. Tropical or Amebic Abscess takes its name from its occurrence 
 especially in the tropics, and as the result of infection with the Amoeba 
 coli. The patient usually gives a history of residence in tropical or 
 semi-tropical climes, and almost always has suffered from dysentery; 
 but as the symptoms of amebic colitis sometimes are very insignificant 
 (p. 896) too much faith should not be put in the patient's history. 
 The hepatic abscess, which usually is single (in 60 per cent, of cases) 
 and of large size, may not develop or at least may not begin to produce 
 symptoms until many years after the occurrence of the primary 
 infection. The ameba is transported to the liver through the portal 
 circulation, and the destructive process begins in the hepatic cells. 
 The abscess usually is in the right lobe of the li^-er, but even when 
 the abscess is very large the shape of the liver may not be noticeably 
 altered. The abscess develops silently, like a cold abscess, and it 
 often produces no symptoms until secondary infection has occurred. 
 ^Mien uninfected by pyogenic organisms the contents are reddish 
 brown in color and vary in consistence from fluid to gelatino-us. 
 Amebfe often cannot be found except in scrapings from the wall of the 
 abscess, or after it has been discharging for several days. 
 
.sT/'/T/.'.t 7717'; IIEIW TITIS 
 
 \YXi 
 
 St/mptonis. Ill niic-tliird of tlic cases, acconiiiif^ to Uouis, there 
 are no symptoms noticed hy the patient until rupture occurs, usually 
 into the lun<js, pleura, or peritoneal cavity. When symptoms exist, 
 they may not he referred to the li\ cr for months after malaise, lassitude, 
 and inereasin<:j weakness are noted. Jaundice is rare. Wlien local 
 s_\inj)tonis are noted tliey frequently are referred to the base of the 
 ri^ht hnifj or the pleura. Fever is anotlier valuable sign, though 
 the tempeniture may not be high except in the evening; in malaria 
 the temj)erature usually rises in the daytime. Enlargement of the 
 liver, and pain (local and referred to the right shoulder) may not 
 occur until late. Diagnosis is aided by purging the patients with 
 salines and searching the stools for amebae, which usually can be found 
 in the third or fourth watery stool. A high leukocyte count in the 
 afternoon is regarded as an indication of the presence of secondary 
 infection. The most common mistakes in diagnosis are (1) failure 
 to recognize the presence of disease of any description; (2) misinter- 
 pretation of the significance and nature of basic pneumonia; (3) 
 attributing the fever to malaria; and (4) mistaking other diseases for 
 abscess of the liver, and vice versa (Manson, 1904). In tropical 
 abscess the spleen is not enlarged. 
 
 Fk;. 899. — Transpleural operation for abscess of the liver: a portion of rib has been 
 excised, subperiosteally; and the diaphragm is being sutured to the tissues or the costo- 
 phrenic sinus. (Deaver and Ashhurst.) 
 
 Treatment. — Treatment involves drainage of the abscess. At the 
 same time proper treatment of the colitis (p. 896) must be instituted. 
 The operation of hepatotomy for drainage of a liver abscess resembles 
 that for subphrenic abscess (p. 814). If the abscess cannot be localized 
 by the physical signs, laparotomy should be done and its position 
 determined. No attempt should be made to localize the abscess by 
 aspiration, except after the liver has been exposed to view. If the 
 abscess is found to be near the convex surface of the liver or if this 
 fact can be determined without opening the abdomen, the abscess 
 should be drained by the transpleural route (Knowsley Thornton, 
 1885) as in the operation for subphrenic abscess: Excise (subperi- 
 osteally) four inches of the eighth, ninth or tenth rib in the mid-axillary 
 line; then suture the diaphragm to the tissues of the costo-phrenic 
 
938 
 
 SURGERY OF THE LIVER 
 
 sinus (deej) layer of costal periosteum, hoth layers of ])leuraj, without 
 opening the pleura, by three or four interrupted sutures of chromic 
 catgut (P'ig. N99). Then make an incision along the upper bonier of 
 the next lower rib, through all structures, diaphragm included, until 
 the liver is exposed. In acute cases the liver is bluish, soft and pulpy, 
 and may bulge into the wound. Adhesions usually shut off the peri- 
 toneal cavity, but it is well tf) isolate the parts with gaw/.e. Where 
 these adhesions are the densest, usually the abscess is found. It is 
 opened b\- a stab with a bistoury, and the tract enlarged by dressing 
 forceps followed by the finger. It is drained by a double tube of rubber, 
 and not until four or fi\e days at least have elapsed should irrigation 
 be eniplo>ed. The sinus may take man\" weeks to close. 
 
 Fig. 900. — Hepatic abscess exposed by flap method. Appendicostomy for accom- 
 pan>-ing colitis. Catheter in the appendix. Recoverj'- (Dr. C. H. Frazier's case.) 
 Episcopal Hospital. 
 
 Echinococcus Cyst. — Hydatid cyst is the result of infection by the 
 Tenia echinococcus, a parasite found in the intestinal tract of dogs, 
 sheep, and other animals. The ova enter the intestinal tract of man 
 with food or drink, or possibly as the result of handling or being licked 
 by an animal infested by the parasite. The capsule is digested in the 
 intestinal tract of the patient, and the embryo is liberated. It bores 
 into the intestinal wall, and in most ca.ses is carried by the portal 
 system to the liver. Hydatid cysts of other organs or tissues are rare 
 and often secondary to a primary growth in the liver. After the para- 
 site (in larval state) reaches the liver, it loses its booklets and enters 
 the immature or cysticercus stage. Inflammatory changes cause a 
 connective tissue encapsulation, so that the cyst wall consists of two 
 layers; an outer laminated layer or capsule, and an inner granular 
 or germinal layer. The contents are clear, colorless fluid, unless sec- 
 ondary infection occurs, when the fluid is purulent; sometimes it is 
 bloody or bile-stained. Hydatid fluid contains a poisonous ptomain, 
 
FAlllSOi'OCCVS CYST 
 
 \w 
 
 which iii;i\ cause coiiN iilsiciiis, rapidity of the |)iilse and respirations, 
 dihited ])iipils and e(>liaj>se. I'liless the parasite dies (hmghter cysts 
 develop within tlie original [jarent cyst. 'I'he heads or scoliees ot" the 
 })arasites ding to the germinal layer in j)edunculated \es»cles known 
 as hrood capsules. These are similar to the j)rimary cyst. The 
 scoliees may become detached and lie free in the hrood capsule, or if 
 this ruptures they may float free in the parent cyst. Degeneration, 
 calcification, and death of the parasites may occur. Hydatid cysts 
 usually occur in the right lobe of the liver and in 90 per cent, of 
 cases the c\st is solitary. 
 
 Symptoms. — The clinical course of the disease much resembles that 
 of tropical abscess' of the liver. So long as secondary infection is 
 absent, and until the cyst grows so large as to project from the surface 
 of the liver, symptoms are inconspicuous. The average duration of 
 the disease before treatment is sought is from five to seven years. 
 Attacks of urticaria are not uncommon. There is danger of rupture 
 (spontaneous or from trauma), into the bile passages, the peritoneal 
 cavity, the gastro-intestinal tract, or the thorax; as well as from 
 secondary infection. 
 
 Diagnosis. — The diagnosis can be made only when a palpable cystic 
 enlargement of the liver is detected. The condition must be dis- 
 tinguished from carcinoma of the liver, which is a solid growth, and 
 usually secondary to a tumor elsewhere; from tropical abscess (p. 93(5); 
 from empyema thoracis and subphrenic abscess; and from gummatous 
 growths (syphilitic) of the liver, which are much more common in this 
 country than hydatid cysts. 
 
 Treatment. — There is no cure without operation 
 downward and are best exposed by laparotomy, 
 that of Quenu; after exposure of the 
 cyst its contents are aspirated by means 
 of a veri/fine trocar and cannula. It is 
 well to insert the trocar through the 
 rubber tube used to drain the fluid from 
 the cannula (Fig. 901), as in this way no 
 dangerof leakage occurs. Then a solution 
 of formalin (1 per cent.) is allowed to run 
 into the cyst cavity and to distend it. 
 This is permitted to remain for five 
 minutes so as to sterilize its contents. 
 It was demonstrated by Deve (1901) 
 that each of the parasitic elements is 
 capable of reproducing the primary 
 lesion, and Quenu found (1902) that 
 formolization as above described steril- 
 ized the contents of the cyst absolutely. The cyst is then emptied, its 
 wall is incised, and the germinal membrane is removed. Then the cyst 
 may be closed by sutures, without drainage, but it should be attached 
 to the abdominal wound so that an intracvstic effusion of bile or blood 
 
 'SLost cysts grow 
 The best plan is 
 
 Fig. 901. — Qucnu's mothod of 
 formolization of hydatid cysts of 
 the liver. 
 
940 SURGERY OF THE LIVER 
 
 can be evacuated easily should either complication occur later. If 
 the old plan of marsui)ialization (opening, packing with gauze, and 
 suturing to the abdominal wound) is employed without formoliza- 
 tion, the condition is analogous to that of a cold abscess opened and 
 drained — secondary infection is almost unavoidable, })iliary effusion 
 is frequent, and tlie sinus takes very long (months) to close. 
 
 Cirrhosis of the Liver. — Pathologists distinguish between portal cir- 
 rhosis, in which the cause is transmitted by the portal circulation, and 
 the obtrusive symptoms are those of portal obstruction; and biliary 
 cirrJiosis in which the essential lesion is a radicular cholangeitis, and 
 the conspicuous clinical feature is jaundice (A. O. J. Kelly). The 
 latter has not, so far, become amenable to surgical treatment, though 
 proper operative treatment of diseases of the gall-bladder and bile- 
 ducts may often prevent its development; and in the former surgery 
 is able only to modify or lessen the distressing symptoms, without in 
 any way bringing about a cure of the underlving disease. 
 
 The main symptoms of portal cirrhosis of the liver are (1) gastro- 
 intestinal hemorrhages, from obstruction of the portal vein, and (2) 
 ascites from peritoneal changes which accompany the disease. Pure 
 portal obstruction is said not to produce ascites, which it is believed 
 is caused almost solely by changes in the endothelium of the peri- 
 toneum; it is in the nature of a chronic serositis, probably due to the 
 toxemia of disordered hepatic function. Cases of portal cirrhosis 
 sometimes are complicated by tuberculosis of the peritoneum, or by 
 a chronic polyserositis associated with cardiac disease; and in such 
 cases it may not be the hepatic toxemia, but the complicating disease 
 which is responsible for the peritoneal effusion. ]Most of the operative 
 methods proposed for the relief of ascites are based on the idea that 
 this occurs as a direct transudate from the portal system. Such is 
 not the case, and a rational operation must seek to alter the nutrition 
 of the peritoneal endothelium; operations which seek to establish 
 a collateral circulation for the obstructed portal system are rational 
 only when gastro-intestinal hemorrhages are present or threaten. 
 
 Paracentesis. — The ascitic fluid may be removed by repeated tap- 
 pings, and in rare instances the fluid finally ceases to re-accumulate. 
 The trocar and cannula should be thrust into the abdomen in the mid- 
 line between umbilicus and pubes, after it has been ascertained that 
 the bladder is empty. Xo anesthetic is necessary, though in nervous 
 patients or when the abdominal wall is thick, a local anesthetic may be 
 used. The patient should be in the semi-recumbent position, and as 
 the fluid is evacuated concentric pressure should be made on the abdo- 
 men by means of a many-tailed bandage, so as to prevent syncope 
 by the sudden relief of pressure on the large abdominal bloodvessels. 
 If the amount of fluid is very great, it is best not to remove all of it 
 at once. The puncture is sealed with collodion, and the abdomen 
 kept tightly bandaged, in an effort to prevent re-accumulation. 
 
 Laparotomy with gauze abrasion of the serous surfaces of the liver, 
 spleen, and diaphragm, in an eft'ort to alter their nutrition, and check 
 
TUMORS OF 1J\ Kh', (;.\/.L ni..\l)l)l'h\ AM) lUI.E DICTS \)[\ 
 
 the f'oniiiitioii ot" tlie ascitic fluid, which is simultaneously cxacuatcd, 
 is a more eflectual method of treatment, and mucli ot" tlie good attrib- 
 uted to e{)i])h)pexy (see beh)vv) is no doubt due to tliese stei)S which 
 form an integral j)art of that oi)eration. 
 
 Epiplopexy, introduced by 'J'alnia (1SS<)) and Aforison (IS!)4), con- 
 sists in suturing the omentum to the parietal i)eritoneum on both 
 sides of the abdominal incision, or between the peritoneum and the 
 posterior sheath of the rectus muscle, in the effort to establish a 
 collateral circulation. As already noted, abrasion of the serous 
 surfaces of the liver, sj)leen, dia})liragm, and of the parietal j)erit()neum 
 forms an integral part of this operation, the idea being that a collateral 
 circulation will be established in the adhesions thus produced. The 
 surest manner of establishing a collateral circulation for portal obstruc- 
 tion is to make an anastomosis between the portal \'ein and \'ena 
 cava (Eck's fistula); this was done by Vidal (1903) in a patient almost 
 exsanguinated by gastro-intestinal hemorrhages; but though these 
 were cured, the ascites was not, and death ensued four months later 
 from acute general infection, evidently enterogenous; the portal 
 blood-stream had been short-circuited and the liver was no longer 
 interposed to the hordes of microbes constantly absorbed from the 
 bowels. 
 
 After epiplopexy the abdomen is not drained, though this formerly 
 was considered essential. Symptomatic relief has been secured in from 
 one-third to one-half the cases. 
 
 Tumors of the Liver, Gall-bladder, and Bile Ducts. — Benign tumors 
 are very rare and have little surgical interest. 
 
 Carcinoma of the Liver may be primary, but in almost all cases is 
 secondary to a growth in the distribution of the portal system. The 
 usual type, whether primary or secondary, is nodular or multiple 
 carcinoma. If this is a primary growth most of the nodules are metas- 
 tases from one original focus which usually is in or near the gall- 
 bladder (Beadles, 1896); while in secondary carcinoma the nodules 
 are scattered all over the liver uniformly, and not massed about the 
 fossa of the gall-bladder. The nodules are whitish, gray, or yellowish 
 masses, from the size of a pinhead to that of an orange, but seldom 
 larger than a walnut. They stand out from the surface of the Vner, 
 frequently cause perihepatitis with resulting adhesions; and when large 
 often become umbilicated as the result of interstitial hemorrhages. 
 If the growth is primary, gall-stones usually are present. 
 
 Syinytoms are not characteristic, and the diagnosis rarely is made 
 until enlargement of the liver, with palpable nodules, and the develop- 
 ment of ascites and sometimes of jaundice, indicate that the disease 
 has passed the operable stage. The symptoms of the secondary 
 growth in the liver frequently o\'ershadow those due to the primary 
 focus in pancreas, stomach or intestinal tract, anfl even at autopsy 
 it may be difficult to find the primary growth. 
 
 Treatment in almost all cases must be palliative; very occasionally 
 a primary growth may be excised, but in most patients the prognosis 
 
942 SURGERY OF THE LIVER 
 
 is hopeless, and death ensues in from fiAe to seven months after recog- 
 nition of the condition. 
 
 Sarcoma of the Liver almost always is secondary, usually to a growth 
 in the eye or the soft tissues of the limbs: but many years occasionally 
 elapse between removal of the primary timior and evidence of hepatic 
 involvement. 
 
 Carcinoma of the Gall-bladder and Bile-ducts is much more common 
 than carcinoma of the liver. Secondary carcinoma is rare and of little 
 surgical impr)rtance. 
 
 Primary Carcinoma of the GaU-bladder is found in about 2 per cent. 
 of specimens removed by cholecystectomy; and almost invariably 
 gall-stones are present and are regarded as the predisposing cause. 
 The growth begins at the fundus or near the neck of the gall-bladder, 
 and extension occurs to the YneT. The early symptoms are those of 
 cholelithiasis; later a hard noflular tumor of the gall-bladder is rec- 
 ognized, but by this time hepatic involvement frequently renders the 
 case inoperable. The most favorable cases are those where a thick- 
 walled gall-bladder removed at oj>eration is discovered to be the seat 
 of carcinoma only when microscopically examined. Such patients 
 may survive several years, whereas those in whom the correct 
 diagnosis is made before or during operation usually die within a 
 year. 
 
 Treatment consists in extirpation of the growth whenever possible. 
 This always should include excision of the entire cystic duct with the 
 gall-bladder and may necessitate removal of the adjoining liver tissue 
 also. [Methods of suture of the liver have already been considered 
 ' p. ^43 . 
 
 Primary Carcinoma of the Bile Ducts presents much the same symp- 
 toms as carcinoma of the head of the pancreas, notably obstructive 
 jaundice, of slow or sudden but almost always painless onset, never 
 remitting but gradually deepening to a bronze or almost black hue. 
 If the growth is in the choledochus. the gall-bladder becomes dis- 
 tended and enlarged, and is palpable through the abdominal wall in 
 half of the cases. If the growth is in the hepaticus (which is rare), 
 no enlargement of the gall-bladder occurs. Disturbance of the 
 pancreatic functions indicates obstruction at the papilla of \'ater. 
 
 Treatment. — Exploratory operation is proper in all but manifestly 
 hopeless cases. If a radical operation cannot be done, the abdomen 
 should he closed tcithout doing anything further. Palliative operations 
 for malignant obstruction of the common duct have a very high 
 primary mortality (hemorrhage from cholemiaj and do not prolong 
 the patient's life nor promote his comfort. If complete extirpation 
 can be done, the draiiaage of bile into the intestine must be restored 
 by some form of biliary-intestinal anastomosis (p. 928). Retro- 
 durxlenal resection of the choledochus in 1^ operations collected by 
 Oppenheimer (1912). gave an immediate m(»rtality of 50 i>er cent. 
 Occasionally a growth at the papilla of \'ater can be excised by a 
 transduodenal operation (Czerny. 1901). The immediate mortality of 
 
INFECTIONS OF THE PANCREAS 943 
 
 this oiHTJitioii, acfordiiig- to ()])iKMilR'iin('r, is oA per cent. Tlic most 
 radical oiHTatioii of all for ^Towths at the lower end of the cliolcdochiis 
 resembles that of cei)halic i)ancreutectomy (p. 951). 
 
 SURGERY OF THE PANCREAS. 
 
 Infections of the Pancreas. 'J'heoretically infection may reach the 
 pancreas, as it may any other organ, (1) through the blood-stream; 
 (2) along its excretory ducts; (3) through its lymphatics; or (4) by 
 contiguity, from neigliboring structures. 
 
 1. Iiifirtioti ihroiKjh the blood is comparatively rare. The pancreas 
 is seldom affected in pyemia; but the occurrence of pancreatitis as a 
 complication of acute parotitis (mumps) though unusual is well 
 recognized (Deaver and Ashhurst tabulate 01 cases); and a few cases 
 of in\()hement of the ])ancreas ha\e been reported in cases of scar- 
 latina, influenza, and other acute infections. In chronic interacinar 
 pancreatitis, also, which is a frequent accompaniment of arterio- 
 sclerosis and which usually results in diabetes, the causative agent 
 is conveyed to the pancreas in the blood-stream; and it is probable, 
 as pointed out below, that acute pancreatitis is the result of some 
 toxin which exerts its action first on the endothelial lining of the 
 bloodvessels. 
 
 2. Infection through the ducts has been produced experimentally 
 by injection of bile, gastric juice, and other irritants, resulting in 
 acute inflammation; but it is not probable that such occurrences are 
 frequent in life, though Opie recorded a case in which a small gall- 
 stone blocked the orifice of the ampulla of Vater and allowed retro- 
 jection of bile into the pancreatic duct. 
 
 3. Infection through the Lymphatics. — The lymph nodes around 
 the head of the pancreas drain the lymph from the gall-bladder and 
 bile-ducts, as well as (more or less directly) from the pylorus, the 
 appendix, and other common sites of intra-abdominal infection. The 
 lymphatics from the remainder of the pancreas are more or less inde- 
 pendent of those about its head, and do not drain such common sites 
 of infection as those already mentioned. The chronic infections of 
 the ])ancreas are almost always confined to the head of the gland, and 
 the fibrous tissue which forms is interlobular in distribution, thus 
 corresponding to the lymphatic tissue; it is true that the blood-chan- 
 nels also are interlobular, but if in these cases of chronic pancreatitis 
 the infection was conveyed by the blood-stream the entire gland should 
 be involved, which is not the case in chronic interlobular pancreatitis, 
 the common form; though it is the case in the rarer interacinar form, 
 in which, as already indicated, the causative agent probably is blood- 
 borne. That the infection does not originate in the excretory ducts, 
 in cases of interlobular oancreatit's, is indicated by the local dis- 
 tribution of the resulting fibrosis, which is neither scattered diflFusely 
 throughout the gland, as are the ducts, nor yet situated close about 
 the parenchyma of the gland in the portion w^hich is affected. It is 
 
944 SURGERY OF THE PANCREAS 
 
 thus evident, as pointed out by Maugeret (1908), tliat the condition 
 commences as a pancreatic lymphangeitis, the term suggested by 
 Arnsperger (1911), and adopted by Deaver and Pfeiffer (1912), who 
 have been particularly instrumental in securing recognition of the 
 disease in this country. 
 
 4. Infection by contiguity is rare, except when a gastric ulcer or 
 carcinoma becomes adherent to or perforates into the pancreas. 
 
 Acute Pancreatitis. — Acute catarrhal pancreatitis is of little impor- 
 tance surgically; it may accompany acute gastroduodenitis, and 
 catarrhal cholangeitis, aiding in producing the obstructive jaundice 
 which is the common expression of these conditions. Acute paren- 
 chymatous pancreatitis is classified as hemorrhagic, suppurative, and 
 gangrenous (Fitz, 1889), terms which indicate the stage of the disease. 
 The suppurative and gangrenous stages frequently are classed as 
 subacute pancreatitis. 
 
 Acute Hemorrhagic Pancreatitis is the commonest form of acute 
 pancreatitis. The adjective hemorrhagic is attributive, not qualify- 
 ing; hemorrhagic inflammation may occur in any organ, but it is 
 especially frequent, and the hemorrhagic tendency is especially marked 
 in the case of the pancreas. It is probable, as long ago indicated by 
 Truhart, that the process commences as an autodigestion of the pan- 
 creas. It is true that under normal conditions the pancreatic juice is 
 activated by a kinase with which it comes in contact only after leav- 
 ing the pancreas; but under abnormal conditions, as pointed out by 
 Carnot (190S), a kinase may be generated within the pancreas itself 
 by the action of leukocytes or bacteria or toxins. These, probably, 
 are conveyed to the organ through the blood-stream, for the lesions 
 in acute pancreatitis are scattered here and there, and are not confined 
 to any particular segment of the gland. The results of the infection 
 are caused by extravasation of the pancreatic juice, whether this is con- 
 fined to the pancreas itself or escapes into the retroperitoneal tissues or 
 into the free peritoneal cavity: the tryj)sin causes hemorrhages and 
 the steapsin causes areas of fat necrosis. 
 
 The disease is more frequent in men than in women, and most 
 patients are of middle or later life, and rather obese. Recurring slight 
 attacks are not very rare, though the surgeon often is not consulted 
 until a fulminating attack occurs, and so far the existence of the dis- 
 ease in milder forms has scarcely ever been recognized. Trauma 
 has in some cases seemed a predisposing cause; in them a hematoma 
 probably had formed , and only when it ruptured and allowed extrava- 
 sation of pancreatic juice, did the symptoms of acute pancreatitis 
 arise. If the abdomen is opened very early in the attack there may 
 be nothing to indicate the pancreas as the seat of disease; after the 
 lapse of a few hours, liowever, there is found a sero-purulent exudate 
 usually blood-tinged and areas of fat necrosis in the omentum, mes- 
 entery, or peripancreatic fat. Hematomas may be observed in the 
 same situations. The areas of fat necrosis occur as minute whitish 
 specks or flakes, dense and rigid, often surrounded by a hemorrhagic 
 
ACl'TE I'.\.\< h'h'A 77 77,s' 04.") 
 
 zone, tuul nut raised I'rom the surl'ucc of the surrouiuJing fat, a fact 
 wliieh aids in distinguishing them from mihary tubercles. Disorgani- 
 zation of the pancreas occurs very early, and microscopical study 
 seldom is satisfactory, a fact which accounts for the uncertainty that 
 still exists as to pathogenesis. If the ])atient lives, gangrene of the 
 pancreas may follow, and the entire lesser peritoneal cavity may be 
 converted into an abscess containing foul-smelling, purulent, chocolate 
 cohered exudate, with pieces of necrotic pancreas floating around loose 
 in the fluid. 
 
 Symptoms and Clinical Course. — Usually symptoms arise so sud- 
 denly and are of such an overwhelming nature that the patient can 
 give no history of previous milder attacks. In most cases seen by 
 the surgeon the disease runs its course in from fi\'e to eight days, 
 death occurring within a week, unless prom])t operation is done. 
 Pain, vomiting, and collapse are the most prominent symptoms. The 
 pain is intense, excruciating, and may cause collapse; it is neuralgic, 
 and colicky in nature, and resembles that due to acute intestinal 
 obstruction, though the latter often begins with mere twinges and 
 becomes severe only after the lapse of hours. The pain of pancreatitis 
 does not shift, it remains epigastric. Collapse may not occur until 
 the liemorrhagic exudate breaks through the capsule of the pancreas. 
 \'omiting is so frequently repeated that it resembles that which occurs 
 in cases of intestinal obstruction; but in the latter the vomiting is 
 projectile and regurgitant and there is little or no nausea. Hiccough 
 is frequent and ^•ery persistent. Dyspnea is said to be present rather 
 often. Physical examination, early in the course of the disease, is 
 unsatisfactory, owing to tenderness and abdominal distention. ]\Ius- 
 cular rigidity is not very great. After the subsidence of the most acute 
 symptoms, toward the third or fourth day, it usually is possible to 
 detect an ill defined tumefaction in the epigastrium, and there fre- 
 quently is tenderness and perhaps palpable resistance in the left loin. 
 The patient continues to be gravely ill; the stomach is unretentive; 
 emaciation is rapid; slight jaundice is frequent; the pulse is weak 
 and running, and the temperature is elevated and perhaps hectic 
 in type. The patient w^ill now die of exhaustion, sepsis, or secondary 
 peritonitis, unless promptly relieved by operation. 
 
 Diagnosis. — Acute pancreatitis must be distinguished from per- 
 foration of the stomach or duodenum, biliary colic, intestinal obstruc- 
 tion, appendicitis, and poisoning by drugs which have been swallowed. 
 In most cases which might be confused with pancreatitis, a history of 
 the affection can be obtained and will lead to a correct diagnosis. 
 Acute pancreatitis is the disease which cannot be recognized as any 
 other affection and which is apt, therefore, to pass undiagnosed. 
 
 Treatment. — ^The abdomen should be opened promptly for purposes 
 of exploration, by an epigastric incision; isolate the upper abdomen 
 by gauze packs ; if a collection of fluid is found in the lesser peritoneal 
 cavity, evacuate it by aspiration; expose the' pancreas (preferably 
 through the gastro-colic omentum), and if it presents no gross lesions 
 60 
 
946 SURGERY OF THE PAXCREAS 
 
 do not incise it, but merely tampon the lesser peritoneal cavity; if 
 there is an abscess or hematoma in the pancreas incise its capsule, and 
 with a blunt instrument carry the incision into the substance of the 
 gland, to secure drainage of all pockets of pus, etc. Then tampon 
 the incision into the pancreas, using a large rubber tube for drain- 
 age in the centre of the tampons. In some cases, especially of 
 subacute pancreatitis, a counter-incision in the left loin should be 
 made. Complications in the biliary tract (which are not frequent) 
 should not be treated at this time, except for very positive indica- 
 tions. 
 
 Abscess or Gangrene of the Pancreas usually is a sequel of acute 
 pancreatitis. The recognition of the condition depends upon atten- 
 tion to the clinical course of the disease, and the detection of evidence 
 of deep-seated tumefaction in the region of the pancreas. The abscess 
 frequently points in the left loin, and if this is the case, it should be 
 opened in this place. In other cases an epigastric incision is made 
 first, and the upper abdomen is explored, and a counter-opening is 
 made wherever it seems most desirable. Guinard (1907) commends 
 the thoracic route (left side), similar to that employed in cases of 
 hepatic or subphrenic abscess. 
 
 Pancreatic Fistula sometimes persists for a long time after an opera- 
 tion for acute pancreatitis. The discharge is exceedingly irritating 
 and the skin should be protected by ointments with mineral base. 
 Antidiabetic diet should be insisted upon, as advocated by Wolge- 
 muth (1912); usually the discharge decreases rapidly after a week or 
 ten days, and the fistula then closes. 
 
 Chronic Pancreatitis. — This may be caiarrhal or interstitial in dis- 
 tribution. The former is believed by Mayo Robson and others to be 
 of frequent occurrence, though it is of slight surgical significance; 
 it frequently accompanies chronic interstitial pancreatitis, and when 
 duct-borne infection was regarded as frequent the catarrhal was 
 believed to be a forerunner of the interstitial form. Chronic inter- 
 stitial pancreatitis occurs in two main forms: interacinar and inter- 
 lobular. The former was mentioned at p. 943, as accompanying 
 arteriasclerotic changes in the pancreas; the lesions involve the entire 
 pancreas (head, body, and tail), the nutrition of the islands of Langer- 
 hans is affected early, and diabetes often results. It is not amenable 
 to surgical treatment. 
 
 The only variety of this disease of surgical importance is chronic 
 interlobular pancreatitis. As already pointed out this begins as a 
 pancreatic lymphangeitis, the primary focus usually being in the gall- 
 bladder or ducts, or in the pyloric region of the stomach or duodenum. 
 If the primary focus of infection can be recognized and properly 
 treated before the process in the pancreas has advanced to the stage 
 of organization and cicatrization (true chronic interlobular pancrea- 
 titis), there is every reason to believe that the pancreas will not be 
 permanently damaged. The disease is commonest in adult males 
 between thirty and fifty years of age. 
 
CHRONIC PANCREATITIS 947 
 
 Symptoms and Clinical Course. — Tlie symptoms of paiK-reatic lym- 
 phantioitis are those of the causative lesion, and the local pancreatic 
 changes are not recofjni/.ed until after the aixlomen has been opened. 
 Then the head of the pancreas is found eniarj^ed, firmer than normal, 
 and the individual lobules are distinctly ])alpal)le, which is not the 
 case in the normal pancreas. In true interlobular pancreatitis, the 
 advanced stage of i)ancreatic lymphangeitis, the head of the pancreas 
 (the body and tail are scarcely ever affected, for reasons already 
 pointed out) is enlarged and hard with a nodular surface; on section, 
 tense bands of fibrous tissue traverse the cut surfaces, accounting 
 for the formation of the well-marked lobules. In some cases the en- 
 largement of the head of the organ can be detected through the 
 abdominal walls. The symptoms are those of the underlying malady, 
 accompanied by certain additional symptoms and physical signs and 
 certain changes in the digestive functions which characterize the 
 condition as one of pancreaiic insufficiency. Moreover, whenever the 
 enlarged head of the pancreas obstructs the common bile duct (which 
 traverses it in two-thirds of cases), there are added sympt(mis of 
 hiliary insufficiency, namely, obstructive jaundice, and its accompany- 
 ing digestive derangements. The consequences of -pancreatic insuffi- 
 ciency are chiefly steatorrhea, and azotorrhea: 
 
 Steatorrhea is an excess of fat in the feces. In health the feces con- 
 tain about 20 per cent, of fat, which represents from 7 to 11 per cent, 
 of the fat taken as food. After suppression of the bile alone the feces 
 contain (iO per cent, of fat; after suppression of the pancreatic secre- 
 tion, 70 per cent, of fat; and after suppression of both bile and pan- 
 creatic juice they contain 90 per cent, of fat (Carnot). Xot only is 
 the proportion of fat in the feces much increased, but very little of the 
 ingested fat is absorbed: instead of only about one-tenth being unab- 
 sorbed, as is normally the case, as much as one-third may be unab- 
 sorbed when bile is absent from the intestinal canal, and when both 
 bile and pancreatic juice are absent 90 per cent, of the ingested fat 
 may be recovered from the feces. Thus where both bile and pancreatic 
 juice are lacking the ingested fat is used hardly at all, and instead 
 of the normal chemical changes in the ingested fat (whereby from 
 35 to 40 per cent, of it is converted into split fats), chemical examina- 
 tion of the feces shows that split fats are reduced at least to one-fifth 
 of normal (R. Gaultier, 1905). It is seldom that excess of fat in the 
 feces is visible to the naked eye. In well marked cases of steatorrhea 
 the passages are bulky, of a silver, gray, or asbestos-like color, and the 
 fat may float on the surface like oil droplets or particles of butter. 
 But such stools occasionally occur in health after ingestion of large 
 quantities of fatty food; and in slighter degrees steatorrhea may be 
 caused by biliary deficiency, diarrhea, and other intestinal derange- 
 ments, so that too much reliance cannot be placed on it as an 
 indication of pancreatic insufficiency. 
 
 Azotorrhea. — This is an excess in the feces of undigested proteid 
 material. In health about 5 or (i per cent, of the nitrogen ingested 
 
948 SURGERY OF THE PANCREAS 
 
 as food is excreted in the feces, whereas in cases of pancreatic disease 
 various investigators have recovered from the feces as much as 32, 
 45, and even 70 per cent, of the ingested nitrogen. This condition 
 occurs, according to Fitz, only when there is extreme diminution of 
 the pancreatic juice, and is significant only when gastric digestion is 
 normal, when the diet contains no excess of meat, and when there 
 is no diarrhea. Schmidt's test consists in determining that the nuclei 
 of the muscle cells of the ingested meat fibres are still intact, as they 
 are digested only by the j)ancreatic juice. Salomons test depends on 
 the fact that lecithin is present in unusual quantities in the feces of 
 patients with pancreatic disease; accordingly if such patients are put 
 on an egg diet, from 0.4 to 1.2 grams of lecithin are excreted in the 
 feces daily, instead of 0.1 gram or less, which is the normal. 
 
 The presence of stercobilin in the feces indicates that there is not 
 complete obstruction to the discharge of bile into the intestines. In 
 cases of obstructive jaundice due to chronic pancreatitis and common 
 duct lithiasis the obstruction is rarely absolute, and a distinct though 
 often subnormal reaction for stercobilin may be obtained: but in 
 carcinoma of the head of the pancreas it is entirely absent or present 
 only in very faint traces. 
 
 Urinary Changes. — As already noted glycosuria seldom occurs in 
 interlobular pancreatitis and when present in this condition appears 
 only very late and usually indicates an incurable lesion. " Alimentary 
 Glycosuria' (that which occurs when an excess of sugar is ingested) 
 is much more apt to occur, and may be a constant phenomenon, if 
 there is serious disease of the pancreas (Wille's test). In interacinar 
 pancreatitis glycosuria is a very frequent and an early symptom, but 
 this disease is not amenable to surgical treatment. 
 
 A "pancreatic reaction" in the urine has been described by Cammidge, 
 which he considers of very great value in the diagnosis of pancreatic 
 lesions. The reaction consists in the crystallization from the urine of 
 an unknown substance, possibly a pentose. Some of those who have 
 most practical experience with the "improved test" of Cammidge 
 speak favorably of its diagnostic value, though it is sometimes present 
 in other abdominal diseases. But Deaver and Ashhurst say, " In our 
 own practice we have gradually come to regard it as of less and less 
 value." In a series of 351 tests made by Kinney for Deaver, it was 
 found that, " roughly speaking, in all the cases in which the condition 
 of the pancreas was determined accurately at the time of operation, 
 this supposedly specific pancreatic reaction was obtained only about 
 two and a half times as frequently when the pancreas was affected 
 as when it was not." 
 
 Diagnosis of Chronic Pancreatitis. — The confidence of clinicians 
 in their ability to diagnose chronic pancreatitis corresponds to their 
 faith in the accuracy and reliability of the various tests for pancreatic 
 function, particularly the Cammidge reaction. The pancreatitis, 
 however, is to be regarded as a complication of some other disease 
 rather than as an independent affection, and it cannot be too often 
 
p.wcREATic cMjrij 949 
 
 emphasized that tlic ciirahle stage of the panereatic afi'ection vanishes 
 when tlie 1\ iiii)haii<;t'itie iiihltratioii and edema gi\e i)hiee to an inter- 
 iohniar selerosis whieh can be no more curable tlian chronic nephritis 
 or cirrhosis of the Hver. 
 
 From the symi)toms and physical signs, locahzation of the (Hsease 
 to the pancreatico-Iie]jatic region ahnost always can be made, but in 
 the differentiation of chronic pancreatitis from disease of the bile 
 ducts there always is a large amount of doubt in the minds of those 
 clinicians whose experience with the Cammidge reaction has been 
 unsatisfactory and disappointing. 
 
 Treatment. — This may ahnost be summarized in the expression 
 treat the cause. In most cases the cause is in the gall-bladder or bile- 
 ducts, and prolonged drainage of the biliary tract allows subsidence 
 of the pancreatic swelling, by overcoming the focus of infection to 
 which it was due. It is not an uncommon thing for a biliary fistula 
 to remain open for months, or for symptoms to recur if it closes too 
 early, in cases of chronic pancreatitis. Mayo Robson and some 
 other surgeons prefer to adopt cholecystenterostomy (p. 934) as a 
 primary operation in such cases; but it seems more logical to attempt 
 to relieve the biliary infection which is present by external rather 
 than by intestinal drainage. The gall-bladder should be sutured to the 
 parietal peritoneum or the anterior sheath of the rectus, as described 
 at p. 931, and the resulting fistula should be kept open for several 
 months; and it is important at the time of operation to make sure of 
 the patency of the common duct by passing a sound through it into 
 the duodenum. 
 
 In some cases of pancreatitis no primary lesion, not even a slight 
 one, can be found in the biliary tract. The pyloric region of the 
 stomach or the duodenum may then be the focus of infection, and if 
 this is determined to be the case, such lesions should receive appro- 
 priate treatment. ^Yhen no other lesion can be discovered ^'autrin 
 advocates attacking the pancreas directly, and especially urges drain- 
 age of the retropancreatic tissues after exposing this region by mobili- 
 zation of the duodenum (p. 933). 
 
 Pancreatic Calculi. — These are of such rarity and so seldom produce 
 recognizable symptoms, that they are of comparatively slight surgical 
 importance. The pathogenesis of the stones is similar to that of biliary 
 calculi, but their composition is very different, most pancreatic calculi 
 being formed largely of calcium carbonate or phosphate. They are 
 not crystalline, usually occur in large numbers strung along the pan- 
 creatic ducts like the beads of a chain, and are faceted only on their 
 ends. They occur five times as often in men as in women, but have 
 been diagnosed during life in very few recorded instances. There may 
 be symptoms of coincident (and perhaps causative) biliary disease, 
 or of pancreatic insufficiency; and as the calculi are impermeable to 
 the a:-ray it might be possible to recognize their shadows in a skia- 
 graph; pancreatic colic, if it occurs, can scarcely be distinguished 
 from that due to biliarv disease. 
 
950 SURGERY OF THE PANCREAS 
 
 Treatment. — Link (1911) collected six operations I'or ))ancreatic 
 calculi, and reported a seventh operation b>' himself. He performed 
 paiicreastostomy (analogous to cholecystostomy) drawing the tail 
 of the pancreas out through the transverse mesocolon, splitting the 
 gland longitudinally, removing the calculi, and stitching a rubber 
 drainage tube in the principal duct. The fistula was still open several 
 months after the operation, but the patient w^as in good health. 
 
 Carcinoma. — Carcinoma is the most frequent tumor of the pancreas. 
 It affects the head of the organ in more than half the cases, corre- 
 sponding thus with chronic interlobular pancreatitis, though there is 
 so far no proof that the latter disease is an etiological factor in the 
 production of carcinoma. The tumor begins as a very small localized 
 growth, usually as scirrhus, and sometimes gives metastases to the 
 liver before it grows large enough to be readily recognized; hence many 
 cases of secondary carcinoma of the liver are considered primary 
 until a minute primary nodule is found in the pancreas. If the growth 
 occurs in such a situation as to block the excretory duct of the pan- 
 creas and to occlude the comrnon bile-duct the resemblance to other' 
 causes of obstructive jaundice (common duct lithiasis, chronic pan- 
 creatitis, tumors or strictures of the choledochus) is very close, and 
 differential diagnosis may be difficult. In most cases, however, of 
 malignant obstruction of the common duct the gall-bladder becomes 
 enlarged (Cuurvoisier's Law, p. 92()), and in very many cases can be 
 easily recognized through the abdominal w^all as a globular tumor, 
 moving with respiration, and continuous with the liver dulness wdiich 
 often also is greater than normal. 
 
 Symptoms and Diagnosis. — There are no pathognomonic symptoms. 
 The original clinical description, given by Bard and Pic (1S88) (which 
 comprised steadily increasing jaundice, enlargement of the gall-bladder 
 and rajjid emaciation) , constitutes a syndrome or group of s}'mptoms 
 common to any lesion which causes obstruction at the papilla of 
 Vater (Fig. 902). A carcinoma of the pancreas may grow in situations 
 other than the head of the gland without producing this syndrome, 
 and various other conditions may cause obstruction at the papilla 
 of Vater and thus give rise to this same group of symptoms. In the 
 typical case of carcinoma in the head of the pancreas, a patient, 
 usually over forty years old, complains for an indefinite period of 
 vague upper abdominal symptoms having no localizing character. 
 Then jaundice appears painlessly, and continuously deepens; the 
 gall-bladder enlarges, and the patient loses weight and strength very 
 rapidly. Pain may or may not be a conspicuous feature. Fever 
 usually is absent. Jaundice never lessens, but continuously grows 
 deeper; signs of pancreatic insufficiency are present, and stercobilin 
 is persistently absent from the feces. 
 
 When the abdomen is opened and the pancreas is examined directly 
 by sight and touch it often is impossible to differentiate carcinoma and 
 pancreatitis. In most cases reliance must be placed on the clinical 
 history of the disease. In pancreatitis the usual cause is biliary infec- 
 
CARCINOMA 
 
 951 
 
 tioii, wliifli seldom is present in ejireinonia. In pancreatitis there are 
 recnrrent attacks of pain, fe^•er, janndice, characteristic of stone in 
 the common ckict; while in carcinoma the onset is insidious, the course 
 of tlie disease is ciironic, and there are no periods of remission, in 
 pancreatitis tiic ^all-hladder is contracted and frial)le, and usually is 
 surrounded i)y adhesions; in carcinoma it is enlarged and distended, 
 and is nuich more tough and resistant than in cases ^f pancreatitis. 
 Treatment. — Medical treatment is the only palliative treatment 
 that is to he countenanced. Puliiathe operations (cholecystostomy 
 and cholccystcntcrostomy arc 
 those a\ailable) neither i)ro- 
 long the patient's life nor 
 promote his comfort, and 
 should be done only when 
 there is a probability that 
 the condition is not malig- 
 nant, and that prolonged 
 drainage of the biliary tract 
 may succeed in overcoming 
 the obstruction of the com- 
 mon duct. Radical operation, 
 which scarcely ever is possi- 
 ble, consists in excision of the 
 head of the pancreas (cephalic 
 pancreatectomy). This implies 
 also resection of the descend- 
 ing duodenum, as removal of 
 the pancreas jeopardizes its 
 blood-supply. The technique, 
 which has been systematized 
 by Desjardins (1907) and 
 Sauve (190S), comprises sec- 
 tion of the pylorus, mobiliza- 
 tion of the duodenum, section 
 of the duodenum on the right 
 of the superior mesenteric 
 arterj^ division of the pan- 
 creas (well beyond the 
 growth), and section of the 
 common bile-duct. Then it 
 remains to reestablish the con- 
 tinuity of the gastro-intestinal tract by gastrojejunostomy; to implant 
 the choledochus into the intestine or stomach; and finally to drain 
 the remaining portion of the pancreas into the intestine (pancreato- 
 enterostomy, Coffey, 1909). If the tumor is in the body of the 
 pancreas, the organ may be resected and its two ends reunited, as 
 done by Finney; or if the tail only is involved, it may be removed 
 and the stump closed. 
 
 Fig. 902. — • Obstructive jaundice: enlarge- 
 ment of the gall-bladder and liver, probably 
 from carcinoma of the head of the pancreas. 
 An inoperable case. German Hospital. (Deaver 
 and Ashhurst.) 
 
952 SURGERY OF THE PANCREAS 
 
 Cysts of the Pancreas. — These are classed as true cysts (those due 
 to retention, cystic neoplasms, hydatid cysts, etc.) and pseudu-cysts 
 (cysts which arise in close association with the pancreas and involve 
 it secondarily). Pseudo-cysts are more frequent than true cysts, 
 and usually are formed by effusions which result from abdominal 
 injuries. 
 
 The affection is commonest in early adult life, and in many cases 
 a history of traumatism can be obtained, though it may have occurred 
 several years previously. The existence of retention cysts, the result 
 of occlusion of the ducts by calculi or chronic pancreatitis, is so rare 
 that it is of pathological interest only. Cystic new growths also are 
 rare, whether benign or malignant, and the cysts which result seldom 
 are large. Traumatic cysts form the vast majority of cases seen by. 
 the surgeon, and they are frequently situated in the lesser peritoneal 
 cavity, having only secondary connections with the pancreas. The 
 contents of the cyst usually are light brown, being tinged by the l)]ood 
 in the original liematoma, or from hemorrhage into the cyst at a 
 later period; and examination often detects the presence of one or 
 more of the pancreatic ferments. 
 
 Symptoms and Diagnosis. — Apart from rather vague digestive symp- 
 toms and recurring attacks of acute epigastric pain, which seldom 
 are entirely absent, there is little on which to base a diagnosis until 
 a tumor can be detected, or at least until it is of such size as to cause 
 pressure symptoms. The latter comprise gastric symptoms, with 
 recurring attacks of pain and vomiting; jaundice from biliary obstruc- 
 tion; and constipation from pressure on the colon. Symptoms of 
 pancreatic insufficiency are rather unusual. The tumor which finally 
 develops may present through the gastro-colic omentum, through the 
 gastro-hepatic omentum, or heJow the transverse colon. The relation of 
 the stomach and colon to the cyst may be determined by percussion, 
 after distending these organs with air. In rare cases the cyst may 
 grow backward into either flank. Most cysts transmit the pulsations 
 of the aorta, but this ceases when the patient assumes the knee- 
 chest posture. Disappearance of a cyst may result from its rupture 
 into the intestinal tract, whereupon large quantities of saliva-like 
 fluid are discharged from the bowel; usually the cyst refills. 
 
 Diagnosis. — A pancreatic cyst must be distinguished from mesenteric 
 and omental cysts; from kidney, suprarenal and hepatic cysts; from an 
 enlarged gall-bladder; from ovarian cysts; from cysts of the spleen; and 
 from aneurysm of abdominal aorta. As a rule the history', the relation 
 existing between the stomach and colon and possibly signs of pan- 
 creatic insufficiency, make the diagnosis fairly certain in most cases. 
 
 Treatment. — Operation is indicated, as there is no hope of spon- 
 taneous cure. If the cyst is small and pedunculated (which is rare) 
 it may be possible to extirpate it completely. In most cases mar- 
 supialization must be done — the cyst being evacuated and its cavity 
 being drained with gauze and tube. Closure of the resulting fistula 
 may be accelerated hy adherence to an antidiabetic diet. 
 
GENEIx'M. DIAdXOSIS OF MiDO.MIXM. 'I'l.MOh'S 9'h] 
 
 SURGERY OF THE SPLEEN. 
 
 Mdst of the conditions which are of surgical interest cause an 
 enlargement of the spleen, and it is important to be able to differentiate 
 an ciihiri;c(l sj)lccii from other abdominal tumors. 
 
 General Diagnosis of Abdominal Tumors. Splenic Tumors. — 'J'hese 
 may be almost of any size, even filling the greater part of the 
 ab(lonien. In most cases, however, the enlargement is greatest on the 
 left side, and the spleen unless fixed by adhesions, moves with respir- 
 ation. The enlarged spleen is so closely applied to the al)dominal 
 wall that it is impossible to insinuate the hand between its upper 
 margin and the costal border; it has a sharp inner border which is 
 almost always interrupted by one, tw^o, or three notches. Splenic 
 tumors always grow forward; they ne^'er produce fulness in the loin. 
 The dulness on percussion extends up to the sixth rib or higher in 
 the mid-axillary line. The colon is first displaced downward, and later 
 lies behind the enlarged spleen, so that any resonance due to it will 
 be in the flank or loin. In many cases of splenic enlargement the 
 blood examination aids in making a diagnosis. 
 
 Kidney Tumors rarely come into close contact wdth the anterior 
 abdominal wall, and even when they do, they also cause marked 
 bulging in the loin. They have a rounded contour, wdth no sharp, 
 notched anterior border. The range of motion is much less than in 
 the case of the spleen, and the tumor does not move with respiration. 
 In all but the very largest tumors the hand can be insinuated between 
 the costal margin and the upper border of the kidney. The descending 
 colon overlies the anterior surface of the kidney and is pushed forward 
 w^hen the kidney enlarges. Thus there is resonance anterior to the 
 tumor and dulness in the loin, which is the reverse of what is present 
 in the case of a tumor of the spleen. Other important differential 
 signs are obtained by cystoscopy, catheterization of the ureters, and 
 examination of the urine. 
 
 Suprarenal Growths give much the same physical signs as kidney 
 tumors, but the colon often is pushed downward instead of forward. 
 Hematuria is frequently present. 
 
 Periphrenic Abscess, apart from evidences of suppuration, resembles 
 enlargement of the kidney rather than splenic tumor. 
 
 Ovarian Tumors. — In the case of a wandering spleen of nearly normal 
 size, which has become fixed in the pelvis, confusion might arise unless 
 a distinct notch could be felt. In other cases ovarian and splenic 
 tumors could scarcely be confused. The upper border of an ovarian 
 tumor is very seldom in actual contact with the left costal margin unless 
 it reaches also to the right costal margin. Ovarian tumors grow 
 upward from the pelvis; they do not move with respiration; and have 
 no sharp border with one or more notches. They extend further 
 across the middle line and cause more symmetrical enlargement of 
 the abdomen. Vaginal examination shows the tumor in close associa- 
 tion with a normal sized uterus, and frequently the pedicle of the cyst 
 
954 SURGERY OF THE SPLEEN 
 
 can be felt through the rectum. There is usually an area of resonance 
 between the upper border of dulness over an ovarian tumor and the 
 normal area of splenic dulness. 
 
 Growths of the Colon at the Splenic Flexure. Alost of these tumors 
 cause intestinal obstruction before a palpable tumor develops, but 
 occasionally a diffuse non-obstructing carcinoma occurs which may 
 have to be differentiated from an atypical enlargement of the spleen. 
 A tumor of the colon has not the definite shape of an enlarged spleen, 
 nor has it the same close apposition to the abdominal wall throughout 
 its extent. It usually is dull to superficial and resonant to deep per- 
 cussion. It seldon moves much during respiration, but unless fixed 
 by adhesions changes its position to a marked extent with changes in 
 the patient's posture. Sooner or later intestinal obstruction and metas- 
 tasis develop, but exploratory laparotomy should be done before this 
 stage is reached. 
 
 Tuberculous Peritonitis. — In this condition, already studied in Chap- 
 ter XXII, tumors of various sizes and shapes may form in the abdomen, 
 and one which forms in the left hypochondrium, particularly if adherent 
 to the spleen, may closely simulate a splenic tumor. But the range 
 of motion is limited by adhesions, and although the anterior border 
 of such a mass may feel (juite sharp and well defined, it seldom ex- 
 hibits a notch similar to those on the spleen. ]\Ioreo\er, other foci of 
 tuberculosis often can be detected, and the tuberculin test may be of 
 value. 
 
 Retroperitoneal Tumors are comparatively rare. The least unusual 
 variety is a diffuse lipoma, which is clinically semi-malignant, tending 
 to recur after partial extirpation. Complete extirpation is not possible. 
 Sarcoma also occurs as a retroperitoneal tumor, usually arising in 
 the lymph nodes. These retroperitoneal tumors usually present within 
 the circle formed by the large bowel, offering to percussion a dull note 
 surrounded by intestinal tympany. Inflation of the stomach and 
 colon, and exmination in the Trendelenburg and knee-chest positions 
 should be employed in obscure cases. 
 
 Causes of Enlargement of the Spleen. — There are two groups of 
 cases associated with splenomegaly: (1) Those in which the blood 
 changes are distinctive (which include most cases of malaria, the 
 leukemias, pernicious anemia, splenomegalic polycythemia, typhoid 
 fever, and kala-azar). (2) Those in which they are not distinctive. 
 A positive diagnosis cannot be made without a blood examination. 
 With the exception of certain cases of malaria, splenectomy is ahsohitely 
 coniraindicated in cases included in the firs^ of these two groups. In the 
 second group (no characteristic blood changes) are included. 
 
 1. Cases in which splenectomy may be necessary (moN-able spleen, 
 cysts, tumors, tuberculosis, abscess, Banti's disease). 
 
 2. Cases in which splenectomy is contraindicated (congestion, infarct 
 and thrombosis, infectious fever, Hodgkin's disease, cases of portal 
 obstruction, amyloid disease, pseudo-leukemia, hereditary and family 
 forms of splenomegaly, etc.). 
 
liANTl'S DISEASE 955 
 
 Movable Spleen. Tliis occurs oftcncst in women, as in the 
 somewhat anak)gous condition of hej)atoptosis, already described. 
 Increased weiglit, from enhirgement, prediposes the spleen to ptosis, 
 but in many cases t)f enlarged spleen adhesions hold the organ in 
 plaee. A mo\al)le spleen is of surgical importance chiefly because 
 of the accidents to which it is subject, notably (iciite torsion of its 
 pedicle. This is aecompanied by paroxysmal pain, with reflex vomit- 
 ing, shook, and perhaps by the later development of gangrene of the 
 spleen and peritonitis. In chronic t(>rsio)i the twist of the j)C(licle is 
 tight enough only to cause congestion of the spleen which leads to 
 perisplenic adhesions. Kecurrent acute attacks may lead to the 
 same results, and the spleen may become fixed in an abnormal position, 
 a condition described as dislocated spleen. 
 
 Diagnosis. The diagnosis of a movable spleen is made by recogniz- 
 ing in the movable tumor the size, consistency, and shape of the 
 normal spleen, and by the possibility of the reduction of the spleen 
 to its normal position when the patient is recumbent. The diagnosis 
 of a dislocated spleen is difficult, owing to the adhesions which obscure 
 its shape. 
 
 Treatment. — If no symptoms are produced it is sufficient for the 
 patient to wear an abdominal support which will tend to keep the 
 spleen in place. In most cases where symptoms are present, splenec- 
 tomy is indicated. Splenopexy does not give satisfactory results. 
 
 Cysts of the Spleen. — Hydatid cysts are extremely rare. By far 
 the greater number of splenic cysts are non-parasitic in type, and 
 most are the result of traumatism, though lymphangeiomatous and 
 sequestration cysts may occur, as well as cystic degenerations following 
 embolism. 
 
 Symptoms. — The symptoms are those usual in cases of splenomegaly 
 and the diagnosis depends on recognition of the cystic character of 
 the enlargement. 
 
 Treatment. — The most satisfactory treatment is splenectomy. 
 
 Abscess of the Spleen may occur in pyemia, but cases of surgical 
 interest usually develop in the course of some infectious fever, espe- 
 cially malaria, and rarely typhoid, dysentery, influenza, and dengue. 
 These abscesses usually are single and of large size. The diagnosis 
 depends on recognition of enlargement of the spleen with general and 
 local signs of suppuration. Treatment usually must be confined to 
 incision and drainage, since perisplenic adhesions render splenectomy 
 difficult or impossible. 
 
 Splenic Anemia, or Banti's Disease, described by Banti in 1888, 
 is characterized by great chronicity and three definite clinical and 
 pathological stages: (1) SimpAe enlargement of the spleen. (2) Enlarge- 
 ment with secondary anemia. (.3) Cirrhosis of the liver with spleno- 
 megaly. The cause of the disease is unknown, but it is believed to 
 be infectious in origin. The great majority of cases begin in early 
 adult life, and the sexes are about equally affected. The disease 
 extends over a period of from five to twenty-five years, and always 
 terminates fatally unless the spleen is removed. 
 
956 SURGERY OF THE SPLEEX 
 
 Pathology. — The spleen enlarges steadily but retains its normal 
 sha])f. The average weight is from 150U to 1750 grams. Usually 
 numerous and dense perisplenic adhesions develop, and the capsule 
 and fibrous trabecule of the spleen undergo hypertntphy, but the 
 most notable change is hyperplasia of the reticular fibres without 
 any marked change in the cellular elements. The ^lalpighian cor- 
 puscles are overgrown with connective tissue, and there is prolifera- 
 tion of the endothelium it the sinuses. Often fairly normal areas of 
 the splenic tissue remain in certain places. The amount of endothelial 
 proliferation may be so great as to cause the characteristic change 
 known as Primitive Endothelioma of the Type of Gaucher. The splenic 
 vein is always more or less sclerosed, and this change may also affect 
 the portal vein. Cirrhosis of the liver does not develop until late 
 in the second stage of the disease, and from this time on the changes 
 cannot be distinguished from those of Laennec's atropic cirrhosis. 
 
 Symptoms and Diagnosis. — The,^r^ stage (simple enlargement of the 
 spleeU) de^"elops insidiously and lasts a long time. There is enlarge- 
 ment of the spleen which may not be discovered until it is of great 
 size, but no other symptoms exist. In the second stage there are added 
 to the splenic enlargement symptoms of anemia (pallor, weakness, 
 dyspnea, palpitation). The anemia is of the chlorotic type — diminu- 
 tion of red blood cells and hemoglobin with a low color index. There 
 is also leukopenia with relative lymphoc\i:osis. But the symptoms 
 of anemia may be out of all proportion to the blood changes. The 
 amomit of urine is decreased, and it contains urobilin and albumin 
 intermittently. Finally the hver begins to enlarge, and subsequently 
 or even pre\'ious to palpable enlargement of the liver, gastro-intestinal 
 hemorrhages particularly hematemesis) occur. This second stage 
 of the disease lasts from eighteen months to several years. With 
 the approach of the third stage the liver diminishes in size, ascites 
 develops, the hemorrhages increase,* the urine is still further diminished 
 and contains urobilin and at times bilirubin, the skin develops pig- 
 mentation and sometimes toward the end of the disease true jaundice 
 occurs. 
 
 ^luch dispute as to minor points still exists, but the above descrip- 
 tion gives the essentials of the clinical course of the disease. The 
 diagnosis usually is impossible in the first stage, which often is classed 
 as "idiopathic splenomegaly." Even after the appearance of anemia 
 differential diagnosis may be difficult. In cirrhosis of the liver gastro- 
 intestinal hemorrhages and ascites with decrease in size of the hver 
 usually appear before enlargement of the spleen. In pernicious anemia 
 the anemia is greater than in Banti's disease, the color index is high, 
 and nucleated red blood cells and poikiloc\-tes are present. In Banti's 
 disease the hemoglobin seldom is below 40 per cent, unless there has 
 been a recent severe hemorrhage, as in Morris Lewis's case. In malarial 
 splenomegaly the parasite usually can be found in the blood, the history 
 of the case is different, and quinine may be curative. Leukemia is 
 disclosed by the blood examination. Splenomegaly in childhood (Fig. 
 
SI'lJCMCCntMY 
 
 \):u 
 
 903) is very dillicult to (listiii^^uisli from Haiiti's disease. Some of tlie 
 eases prohahiy are Haiiti's disease. 'Die pseudojcithcniia iufautium of 
 von Jaivseh iisuallx' a])i)ears in the second year of life, is characterized 
 b}' very _ii;ra\e anemia (red blood cells, 1, ()()(),()()(); normoblasts; poikilo- 
 cytosis), by leukocytosis (15,()(){) to 
 20,000) and lymphocytosis. There is 
 marked si)lenonu>yaly and usually 
 moderate enlargement of the liver. 
 Banti's disease must also be distin- 
 guished from syphilitic s-plenomcgahi, 
 amyloid spleen, and horn fa mil y types 
 of splenomegaly in childhood. Hemo- 
 lytic splenomegaly, recently described 
 by Banti, which resembles both 
 Banti's disease and hemolytic jaun- 
 dice, is cured promptly by splenec- 
 tomy. 
 
 Treatment. — The only treatment 
 which has any effect on the disease 
 is removal of the spleen, and this is 
 effective only if done before cirrhosis 
 of the liver (third stage of disease) 
 develops. The presence of slight 
 ascites, with enlargement of the liver, 
 which occurs in the end of the second 
 stage of the disease is not a contra- 
 indication to splenectomy, as these 
 symptoms do not indicate irremedi- 
 able changes in the liver. The immediate mortality of splenectomy 
 is lowest in the first stage of the disease, and increases the longer 
 the operation is postponed. The average immediate mortality is about 
 25 per cent. ; permanent cure results in almost all cases where oper- 
 ation is done in the first stage, in from 50 to 75 per cent, of those in 
 the second stage, and in few or no cases in the third stage. 
 
 Splenectomy. — The best incision is one on the left corresponding to 
 Czerny's gall-bladder incision (Fig. (S92). If no adhesions are present 
 the operation is not difficult. The most important point is the control 
 of hemorrhage. The capsule of the spleen and the veins in its pedicle 
 are easily torn. It is best if possible to separate adhesions first, and 
 to cut the lienophrenic ligament and then rotate the spleen toward 
 the mid-line. If the hand can be introduced gently between the spleen 
 and diaphragm, the former may be drawn down into the wound. 
 If the vessels in the pedicle are not too large they should be clamped 
 close to the spleen, and the spleen removed after cutting between the 
 clamps and the spleen. In some cases the tail of the pancreas is cut 
 oft" also (i\Iayo), but if carefully sutured no fistula will result. Unless 
 there is enough tissue left in the pedicle for the safe application of 
 ligatures it is best to leaA'e the clamps in place for several days. In 
 most cases it is well to leave a gauze drain in the wound. 
 
 Fig. 903. — Splenomegaly in a child 
 aged three and a half years. (Dr. 
 Newlin's case.) Pennsylvania Hos- 
 pital. 
 
CHAPTER XXV 
 
 SURGERY OF THE BLADDER AND KIDNEYS. 
 
 Genito-ueixary surgery has been developed into such a specialty 
 of late years that it is impossible in a text -book such as this to do more 
 than indicate in the briefest possible manner the general principles 
 of diagnosis and treatment of most of the affections, and to describe 
 in somewhat greater detail, but by no means at full length, those 
 conditions of common occurrence which are constantly encountered 
 in general practice. 
 
 GENERAL DIAGNOSIS OF URINARY DISORDERS. 
 
 The surgeon must study the urine or other secretions discharged 
 from the urethra, and examine the genito-tirinary organs themselves. A 
 thorough examination includes macroscopical and microscopical study 
 of urethral discharges (both those which are apparent, and those 
 obtained after stripping the prostate and seminal vesicles, p. 1013); 
 chemical and microscopical study of the urine, which should be 
 collected in three glasses for macroscopical inspection ; instrumentation 
 with soimd or catheter; and cystoscopic examination. In many cases 
 bacteriological study of the urine, pus, etc., also is necessary. 
 
 Fig. 904. — 1, soft rubber catheter. 2, metal catheter. 
 
 Catheters. — Catheters are hollow tubes designed to draw off the con- 
 tents of the bladder (Fig. 904). If they are of metal (usually nickel- 
 plated) they must have a curve corresponding to that of the urethra. 
 Sir Henry Thompson's instruments were curved at the point through 
 an arc which corresponds to the fourth of the circumference of a circle 
 whose diameter is three and one-quarter inches. Flexible catheters 
 have no fixed curve; they are of two principal kinds: the soft rubber 
 catheter (Xelaton's), and the English catheter. The latter is made 
 of webbing and is covered with shellac. It is provided with a stylet, 
 and when used with th's in place, is fairly rigid; or if used without the 
 
GENERAL DIAGNOSIS OF URINARY DISORDERS 959 
 
 stylet, as is safer and eiistoinary, may he made to retain any eurve for 
 a short time by mouldinfj it in warm water and tlien quiekiy phniging 
 it into cold water wlien it becomes stiti'. A catheter should be ten or 
 eleven indies long, and i)rovided with one or two large, smoothly 
 finished eyes Tiear its vesical extremity; all catheters sliould 1)6 solid 
 from the eye to the point, thus leaving no i)ocket for the accumula- 
 tion of decomposing blood or inspissated pus. An English catheter 
 sliould have the eye woven in its manufacture, not punched out after 
 the catheter has been made; and if used with the stylet, great care 
 must be taken not to have the stylet so long that there is danger of its 
 protruding from the eye. The calibre of urethral instruments usually 
 is based on the French scale, which gives the diameter in thirds of a 
 millimeter (practically tlie circumference in millimeters). The sizes 
 in common use range from 10 to 40; the average adult urethra accom- 
 modates a sound of from 30 to 32 Fr. A rigid instrument smaller than 
 Xo. 10 is dangerous and should not be used. 
 
 Introduction of the Catheter. — The greatest damage may be inflicted 
 from neglect of proper antiseptic and aseptic precautions. [Metallic 
 and soft rubber instruments may be boiled just before use; but as 
 webbing instruments will be ruined by heat, they should be soaked in 
 a 5 per cent, solution of formalin (cold) for twenty minutes and before 
 being used should be rinsed in cold sterile water, as the formalin solu- 
 tion might cause urethritis. The patient should be lying down; 
 and the surgeon after washing his own hands (and wearing gloves if 
 possil)le) should retract the patient's foreskin, and w^ash the glans well 
 with soap and water and rinse it in alcohol. The instrument should 
 be well lubricated with some sterile oil, such as a preparation of Irish 
 moss, or glycerin; and it often is well to distend the urethra by inject- 
 ing the lubricant directly into it from a sjTinge. A soft catheter is 
 introduced by inserting its point in the meatus and gently pushing 
 it onward into the bladder little by little, always holding it close to 
 the glans penis. A metallic instrument is most easily inserted while 
 the surgeon stands at the patient's left. After raising the penis in the 
 left hand the surgeon gently inserts the tip of the instrument within 
 the meatus, while its shaft lies along the left groin. Then without 
 raising the shaft from the plane of the body, it is carried over to the 
 mid-line, as the tip of the instrument sinks into the penile urethra; 
 it should enter by its own weight and should not be forced. Not 
 until the point has reached the bulbous urethra should the handle 
 be raised from the patient's abdomen. As the handle is gently raised 
 the point glides under the pubis, traverses the prostate, and enters 
 the bladder (Fig. 905). If the handle is raised too soon the point 
 will catch in front of the triangular ligament. When the point has 
 successfully passed this region, and the handle of the instrument is 
 nearly vertical, the left hand may be placed on the convexity of the 
 instrument, in the perineum, and thus guide it into the bladder. 
 When the catheter has entered the bladder it can be rotated freely in 
 the urethra, on its own axis, and its shaft lies between the patient's 
 
960 
 
 SURGERY OF THE BLADDER AND KIDNEYS 
 
 thighs making an angle of 45° or less with the horizon. An instrument 
 may also be passed from the patient's right side by the manoeuvre 
 known as the tour de maitre: the instrument is introduced with its 
 convexity upward, and as its point reaches the bulb the shaft is 
 swept around toward the abdomen, and is raised to the vertical and 
 then depressed between the patient's thighs as the instrument enters 
 the bladder. 
 
 Fig. 905. — Method of introducing a metal catheter. 
 
 Cystoscopes. — A cystoscope is an instrument designed to permit 
 visual inspection of the interior of the bladder. In the female it is 
 possible to accomplish this by direct vision, usingja narrow speculum 
 (Kelly's cystoscope) and placing the patient in the knee-chest or 
 exaggerated Trendelenburg position so as to allow the bladder to 
 become distended with air so soon as the speculum is introduced. In 
 
 Fig. 906. — Illumination of anterior vesical wall by Xitze's cystoscope. (Park.) 
 
 men, however, it is necessary to have an instrument somewhat resem- 
 bling a catheter, provided with an electric light at its vesical extremity 
 and a series of lenses by which the image is transferred to the outer 
 end of the instrument where the examiner's eye is placed (Fig. 906). 
 In most cystoscopes, the system of lenses reverses the image, but by 
 inserting another lens, the image may be righted again; this, however, 
 
GENERAL niAdXOSIS OF Ch'IXAh'Y DISOliDEUS 001 
 
 iiiiikos tlie ajjparatus more comijlitated and cuts down the amount ot" 
 lifi;ht. Cystoscopio examination requires skill and practice, and should 
 not l)c attempted without ample training. In many eases it may he 
 accomplished alter anesthetizing the deej) urethra with a 4 jx'r cent, 
 solution of eucain, hut sometimes a general anesthetic is required. 
 Before the cystoscope is inserted the bladder should be emptied of 
 urine, and irrigated if necessary to cleanse it of blood or pus; about 
 four ounces of solution are left in the bladder. Then the cystoscoj)e 
 (sterilized in carbolic acid or formalin solution — it cannot be boiled) 
 is introduced, and after its point is within the bladder, the electric 
 current is turned on, and the examiner proceeds to inspect the interior 
 of the bladder. The ureteral orifices may be seen and the swirl of 
 urine discharged from each may be readily recognized, as also the dis- 
 charge of blood or pus instead of urine. The condition of the vesical 
 mucous membrane is also studied; foreign bodies, tumors or calculi 
 are searched for; the presence and situation of the orifices of diverticula 
 are located, etc. Some cystoscopes are provided with slots through 
 which a fine catheter may be passed, for the purpose of catheterizing 
 the ureters; and through some it is possible to insert delicate instru- 
 ments and under the control of vision make applications to ulcers, 
 cauterize or snare oft' tumors, remove small foreign bodies, etc. An 
 endoscope is an instrument similar to a cystoscope, but designed to 
 examine the interior of the urethra. 
 
 Estimation of the Functional Capacity of the Other Kidney. — Always 
 before one kidney is removed, and in a great many other cases, it is 
 necessary for the surgeon to determine the functional capacity of the 
 healthy (or less diseased) kidne}'. The simplest way to do this is by 
 chromoureteroscopy, by means of the indigo-carmine test; this was 
 introduced in 1903 by Volcker and Joseph, and has been popularized 
 in this country by B. A. Thomas: 20 c.c. of a 0.4 per cent, solution, or 
 4 c.c. of a 4 per cent, solution of indigo-carmine are injected hypoder- 
 mically, and a cystoscope is introduced. The urine is stained blue, 
 and if the kidney is healthy the stain will appear in the urine as it is 
 discharged from the ureter of the kidney in question Avithin nine 
 minutes of the time it was injected hypodermically, A delay of more 
 than twenty minutes in the appearance of the stain indicates serious 
 incompetency. 
 
 Other methods in\'olve the collection of urine from each kidney 
 separately. This is best accomplished by catheterization of the ureters. 
 Then one may use, in addition to the ordinary chemical and micro- 
 scopical tests of the separate urines, also what is known as the yhenol- 
 sidphonephthaJein test, which is highly commended by H. H. Young: 
 "The patient is given three glasses of water to drink, and is then 
 catheterized and the bladder washed out just before inserting 1 c.c. 
 of fluid containing (i mg. of the drug intramuscularly or intravenously. 
 The time of the appearance of the first faint pinkish tinge as the urine 
 escapes from the catheter into the test-tube, made alkaline by adding 
 a drop of 25 per cent. XaOH solution, is noted as the beginning of the 
 61 
 
962 SURGERY OF THE BLADDER AXD KIDNEYS 
 
 test." In healthy patients the drug appears in the urine about seven 
 minutes after it is administered; 40 to 60 per cent, is excreted in the 
 first hour, and from 20 to 25 per cent, in the second hour. The phlo- 
 ridzin test is less accurate: this is based on the power of the normal 
 kidney to excrete sugar within a given time; the diseased kidney loses 
 in part or entirely its permeability to sugar. After the ureteral cath- 
 eters are in place, 20 minims of a 1 per cent, solution of phloridzin 
 are injected hypodermically; glycosuria should appear within from 
 fifteen to thirty minutes, and usually disappears after three hours. 
 Cryoscopy, the estimation of the freezing-point of the blood and urine, 
 is rather a complicated test, and of uncertain value. 
 
 SURGERY OF THE BLADDER. 
 
 Exstrophy of the Bladder is a congenital deformity due to a defect 
 in the closure of the hypogastric region of the abdominal wall. The 
 pubic bones often are ununited, and epispadias Tp. 1045) and sometimes 
 inguinal hernia may also be present. The deformity is much commoner 
 in male than in female children. The anterior wall of the bladder 
 being absent, the intra-abdominal pressure forces out the posterior 
 wall, and the mucous surface presents itself as a red, moist protrusion, 
 often with the ureteral orifices readily visible. Urine dribbles con- 
 stantly, the mucous membrane and surrounding skin become much 
 inflamed, and ascending infection of the kidneys almost invariably 
 follows; it is said that in about half the cases death ensues from this 
 complication before the tenth year. 
 
 The only effective treatment is by operation, of which there are two 
 main classes: 
 
 1. Those which aim to cover in the protruding bladder wall by some 
 form of plastic operation. Of these methods the best is that of John 
 Wood (1865), in which a cutaneous flap from below the umbilicus 
 is inverted over the bladder, and is covered by two flaps slid inward 
 from the groins, or by one large "bridge flap" from the scrotum 
 (Richard). Though this does not restore sphincteric control, it 
 narrows the opening for the discharge of urine and makes it possible 
 for the patient to be kept clean by wearing a urinal; but in many 
 cases cystitis occiu-s and vesical calculi form, and ascending kidney 
 infection causes death. ^Moreover, if hairs grow on the inverted skin 
 surface they cause additional trouble. 
 
 2. The other plan of operation, and that which is most in favor 
 at the present day, consists in transplanting the ureters or, preferably, 
 the base of the bladder containing the ureteral orifices, into the large 
 bowel (rectum or sigmoid), thus allowing the urine to collect in the 
 rectum where it may be retained by the sphincter several hours at a 
 time. Here also, however, there is great danger of ascending kidney 
 infection, even when the valve-like insertion of the ureters in the 
 bladder wall remains intact in the transplanted segment; and the 
 primary mortality is even higher than in the autoplastic methods. 
 
CYST IT IS 9«3 
 
 Urachal Cysts and Fistulae. II' the jilliintoic duct of the cinhryo 
 fails to close at tlic uiiiMlicus a fistula remains whidi may discliarf^e 
 urine it" it is patent all the way down to the hiadder, or wliicli if closed 
 at its vesical end may discharge only nnicoid lluid. Sometimes a 
 fistula of the nrachus will close spontaneously affer obstruction to the 
 natural outflow of urine is removed, hut in most cases excision of the 
 fistulous tract is retpiired. If the urachus closes at both ends, a cyst 
 may form in its course. These urachal cysts seldom jj;ive rise to 
 reco,u:ni/,al)le symi)toms, and usually are found unexpectedly at 
 oi)eration. Excision is the proper treatment. 
 
 Cystitis. Inflammation of the urinary hiadder in almost all cases 
 is caused hy hacteria, which are introduced from without or which 
 reach it through the urine d(>livered from the kidneys, llnless there 
 is ohstruction to the outflow of urine throuj^h the urethra it is difficult 
 to infect the healthy bladder with germs of ordinary virulence, and 
 hactcrluria (see helow) may exist a long time without the occurrence 
 of cystitis. An ordinary mild attack of cystitis tends to spontaneous 
 recovery; but the occurrence of congestion of the hiadder (from internal 
 medication, exposure to cold, instrumentation, etc.) predisposes it to 
 infection, as does the presence of foreign bodies (calculi). Unclean, 
 or e\en clean catheterization, if frequently repeated, is the most 
 frequent cause of cystitis; but extension backward of an acute or 
 chronic urethritis, or the descent from the kidney of urine contaminated 
 with tubercle or typhoid bacilli, are other usual causes. Colon bacilli 
 are those most often introduced by instrumentation. 
 
 The usual changes met with in inflammation of mucous surfaces 
 are present: an abundant mucous secretion, desquamation of epithe- 
 lium, and if the infection is severe, ulceration of the bladder. Perfora- 
 tion is excessively rare. In cases of long standing, infiltration of the 
 bladder wall occurs, the muscular coat is more or less replaced by 
 fibrous tissue, and as this contracts the capacity of the hiadder is 
 much decreased and its elasticity is destroyed. 
 
 Symptoms. — Pain, frequency of urination, and changes in the com- 
 position of the urine, are the cardinal symptoms of cystitis. The 
 pain, which is felt mostly in the perineum or behind the pubis, varies 
 with the acuteness of the attack, and may be present only during 
 urination, or there riiay be a constant burning or sense of weight. 
 The urine is passed frequently, in small quantities, and with consider- 
 able tenesmus; it is clouded l)y pus and mucus, and occasionally is 
 blood-stained. The pus will cloud all the urine, wdiether this is collected 
 in one, two, or more glasses. In acid urines are found the B. coli 
 conmumis, B. tuberculosis, B. typhosus, pneumococcus, and gono- 
 cocc-us; in alkaline urines, staphylococci, streptococci, B. proteus, etc. 
 Constitutional symptoms are unusual except in very severe grades 
 of acute cystitis, and they often indicate renal complications. 
 
 Treatment. — ^As already noted, most eases of cystitis tend to spon- 
 taneous recovery unless there is urethral obstruction, or unless the 
 infecting source continues active. The first point in treatment is to 
 
9G4 SURGERY OF THE BLADDER AXD KIDXEYS 
 
 determine the source of infection and remove it. If na exterior source 
 can be determined, and if no urinary obstruction exists, it is probable 
 that the kidney is at fault. If cystoscopy cannot be done the fact 
 that the cystitis has its origin in an infected kidney often must be 
 surmised only by exclusion of all other factors, and by noting pain 
 and tenderness over, and perhaps enlargement of the kidney. 
 
 In the Acute Stages. — Put the patient to bed and keep him on a 
 liquid diet, with plenty of water, and some demulcent such as flaxseed 
 tea. x\n alkaline diuretic should be given, especially citrate or acetate 
 of potash; and when the most acute symptoms subside, some anti- 
 septic such as phenyl salicylate or hexamethylenamine may be admin- 
 istered. Watson says the urine should be made alkaline before these 
 are employed, to avoid too great irritation of the bladder; others 
 think hexamethylenamine is valueless so long as the urine is alkaline. 
 If there is much pain or violent tenesmus, no hesitation should be 
 felt in giving opium and belladonna by rectal suppositories or hypo- 
 dermically. Local hot applications (sitz-baths) are grateful to the 
 patient; and in case retention of urine (p. lOloj occurs, every such 
 method should be tried before resorting to catheterization, and if this 
 becomes necessary' only a soft instrument should be used. 
 
 When the chronic stage is reached much good may be accom- 
 plished by irrigation of the bladder. Saline or boric acid solution 
 may be used in ordinary cases, and in more rebellious cases per- 
 manganate of potash (1 to 8000) or silver nitrate solutions (I to 
 2000 to 1 to 100). Irrigation of the Bladder is best accomplished 
 through a soft catheter, to the outer end of which a small funnel is 
 attached; the fluid is then allowed to run in gently by the force of 
 gravity. By inserting a nozzle just within the meatus, and raising 
 the reservoir to a height of from three to five feet, it is possible to 
 overcome the sphincter and irrigate the bladder without the intro- 
 duction of a catheter; but unless very skilfully done this method is 
 more painful. Not more than a couple of ounces should be introduced 
 at first, but after several sittings which should take place every second 
 or third day, the amount may be increased up to the tolerance of the 
 bladder. The surgeon should not imagine, however, that he is opera- 
 ting by a species of hydraulic mining, and no force whatever must 
 be employed. In chronic cystitis with urinary obstruction it often is 
 well to let the catheter remain in place, thus securing better drainage; 
 and as a last resort it may be necessary to perform suprapubic or 
 perineal cystotomy to secure free drainage. 
 
 Bacteriuria. — Bacteriuria is a condition in which bacteria are found 
 in large quantities in the urine, but in which local symptoms are 
 slight or absent. The bacteria most often encountered are the colon 
 and typhoid bacillus and the Staphylococcus albus. The source which 
 supplies the bacteria (kidney, prostatic urethra) should be deter- 
 mined and suitably treated. Bladder irrigations are of no use; but 
 deep injections into the prostatic urethra, or irrigation of the kidney 
 pelvis after catheterization of the ureter, usually prove efficient. 
 
TUBERCrLOSIS OF THE /if.ADDEh' 905 
 
 Wlion no source of infection can be detected, a prolonged course of 
 urinary antiseptics, or administration of autogenous vaccines may 
 pro\c curative. 
 
 Diverticula. I)i\erticula of the bladder sometimes occur in cases 
 of chronic cystitis, usually as the result of back pressure from urethral 
 obstruction. They are most frequent on the extraperitoneal surface 
 of the bladder. 'J'he urine which X'oUects in them stagnates, and 
 calculi fre(|ucntly form. Occasionally perforation occurs. The diag- 
 nosis is best made by cystoscopy; but occasionally the presence of 
 a diverticulum may be suspected if residual urine is found sometimes 
 but is entirely absent at other times, or if after washing out the 
 bladder until the solution returns clear, a sudden gush of purulent 
 urine occurs. 
 
 Treatment. — The only satisfactory treatment is excision of the diver- 
 ticulum; at the same time, or previously, all causes of urinary obstruc- 
 tion should be overcome. If operation is refused, temporary improve- 
 ment may be secured by vesical irrigation and treatment of the urinary 
 obstruction. 
 
 Tuberculosis. — Tuberculosis of the bladder almost always is sec- 
 ondary to the disease elsewhere in the body, especially in the kidney 
 or epididymis. Although constantly exposed to infection when the 
 secretions of these organs enter it, the bladder successfully resists 
 infection for a long time, and even when infected is able for a long 
 time to recover its health spontaneously if the source of infection is 
 removed. If this source is the kidney, the vesical lesion begins around 
 the ureteral orifice; while if infection is received from the ejaculatory 
 ducts tlu-ough the urethra, the vesical trigone is the part first affected. 
 The affected areas are at first mere patches of congestion ; then whitish 
 tuberculous nodules appear, break down, and form small round ulcers 
 which tend to preserve this typical rounded form even when they 
 have coalesced. Advent of mixed infection causes rapid spread of 
 the lesions 
 
 Symptoms. — Frequency of urination is the earliest, and for a long 
 time may be the only subjective symptom, though blood in micro- 
 scopic quantities usually will be found in the urine if looked for. As 
 the process advances, urination becomes excessively painful, there is 
 great and incessant tenesmus, and the pain is referred to the end of 
 the penis, the thighs, and the perineum. The urine is acid, increased 
 in quantity, and in time becomes intermittently or constantly bloody 
 and shreddy. By this time signs of tuberculosis elsewhere in the 
 body usually have appeared. The finding of tubercle bacilli in the 
 urine may be very difficult, but innoculation experiments may serve 
 to confirm the diagnosis. 
 
 Treatment. — In addition to the general treatment suitable in every 
 case of tuberculosis, it usually is possible to cause arrest or even 
 complete cure of the vesical lesion, if the primary focus (kidney, 
 testicle, etc.) is removed. Even if both kidneys are diseased, it seems 
 that the removal of the more diseased organ improves the condition, 
 
966 SURGERY OF THE BLADDER AND KIDNEYS 
 
 not only of tlic Ijladdcr, but of tlu' reiiiaiiiiiig kidney. In cases in 
 which the disease seems i)riniary in the bladder, local treatment may 
 be relied on. Bransford Lewis recommends injecticjns into the bladder 
 of iodoform emulsion, or distention of the bladder by air. As a last 
 resort suprapubic drainage may be adopted to promote euthanasia. 
 
 Tumors of the Bladder, except papilloma and carcinoma, are rare. 
 In children sarcoma sometimes is seen. Pathologically, papilloma 
 is a benign neoplasm, but clinically it reseml)les malignant tumors 
 in its tendency to recurrence, and according to some authorities it 
 frequently undergoes carcinomatous transformation. So long as it 
 is benign clinically it forms a more or less j)edunculated villous 
 tumor, with a })ase which moves freely on the muscular wall of the 
 bladder. Carcinoma is hard, nodular, infiltrating, and becomes fixed 
 to surrounding structures, such as prostate or vagina. 
 
 Symptoms. — The earliest symptom of a vesical tumor is hematuria, 
 which is usually painless at first, and characterized by the irregularity 
 of its occurrence. It may be profuse, and eventually causes grave 
 secondary anemia. Malignant tumors may be excessively painful, so 
 that examination without a general anesthetic may pro\'e impossible. 
 The usual occurrence of cystitis adds its symptoms to those due to 
 the vesical tumor itself. The diagnosis is best made by cystoscopy, 
 taking means to secure a clear medium by the local use of adrenalin 
 to check bleeding or by constant irrigation. If this is impossible, 
 suprapubic cystotomy, which often is required for treatment, may be 
 used for diagnosis. 
 
 Treatment. — Small and well pedunculated papillomas may be re- 
 moved by the operating cystoscope by snaring and cauterization of 
 their bases. Larger or recurrent growths require suprapubic cystotomy, 
 with wide excision of mucosa with the pedicle, the wound being 
 cauterized and the bladder drained. ]\Ialignant growths require ex- 
 cision of the entire thickness of the bladder wall. Sometimes this 
 involves extirpation of the bladder, with transj^lantation of the 
 ureters into the rectum or the skin of the loin; or bilateral nephros- 
 tomy may be done. The mortality is about 30 per cent., and about 
 half the patients have recurrence within a year. P'ulguration is effi- 
 cient in many benign tumors, and may be repeated in case of recur- 
 rence, and often is useful as a palliative measure in otherwise 
 inoperable conditions. 
 
 Vesical Calculus. — The pathogenesis of urinary calculi is discussed 
 in connection with kidney stones (p. 977). The majority of vesical 
 calculi have descended from the kidneys where they were originally 
 formed. Such stones are composed of uric acid, having been formed 
 in acid (uninfected) urine. But while lying in the bladder they may 
 subsequently become encrusted with triple phosphates, if the urine is 
 alkaline and cystitis is present. Pure phosphatic calculi may also be 
 formed in the bladder, under the conditions just mentioned. Calculi 
 of amorphous phosphates, however, are formed in urine which is alka- 
 line or neutral when it leaves the kidney, and are not caused by ^'esical 
 
VESICAL CALCULUS 967 
 
 iiileclioii ami alkaline (locoinpo^sition ot" iiriiii' in I he Madder us are 
 those composed of triple phosphates, (calculi of oxalate of lime (called 
 niulhcrrt/ calculi from their ai)pearance) are next most frequent to 
 calc-uli composed of nric acid and triple j)liosphates, which together 
 form 90 per cent, of all urinary calculi, more than hall" of all calculi 
 being uric acid. 
 
 Vesical calculus is more frequent in men, and in children, than in 
 women. In women aufl children phosphatic calculi are very rare. 
 ( "alcnli \ ary in si/.e from those just too large to he passed sj)ontaneously 
 to those which fill the bladder. Calculi small enough to he passed 
 through the urethra (usually less than 1 gram in weight) are classed 
 as gravel. A calculus weighing more than a few ounces is rare. 
 I'sually only one calculus is present, and very .seldom are there more 
 than five or six. 
 
 The chief predisyosing causes for the formation of calculi in the 
 bladder are urinary obstruction and vesical infection. Hence most 
 j)hosphatic calculi are met with in cases of stricture of the urethra 
 and enlargement of the prostate. Foreign bo(Hes in the bladder 
 (broken ends of catheters, etc.) usually become encrusted with phos- 
 phates owing to the development of cystitis. If there is no obstruc- 
 tion and the urine remains acid, stones very rarely form in the bladder, 
 and those which descend from the kidne}- may be passed by urethra. 
 
 Symptoms. — Pain and hematuria are the chief symptoms. The pain 
 is characterized by two features: (1) It is made worse by motion, 
 exercise, jolting in a carriage, etc.; and (2) it occurs especially at the 
 end of urination, when the bladder contracts on the calculus. The 
 pain is felt in the neck of the bladder and is referred mostly to the 
 glans penis, and sometimes to the perineum, rectum, or thighs. Per- 
 sistent tenesmus may produce prolapse of the rectum or hemorrhoids. 
 Sometimes hyperacid urine, in the absence of calculi, may cause similar 
 symptoms; and sometimes a calculus lodged in a diverticulum or 
 behind an enlarged prostate may be so fixed as to cause no distinctive 
 symptoms. Bleeding occurs irregularly, rarely being profuse. It is 
 increased by motion, and seldom appears except at the end of urina- 
 tion. The blood is bright red, as if recent. 
 
 Diagnosis. — The diagnosis of vesical calculus depends upon detecting 
 tlie stone by a sound, by cystoscopy, or by skiagraphy (Fig. 907). 
 A vesical sound, or stone searcher (Fig. 910) resembles an ordinary 
 urethral sound except that its shaft is smaller and longer, and its beak 
 shorter and more abruptly curved. Before sounding about 4 ounces of 
 fluid should be injected into the bladder, if this has been recently emp- 
 tied. Fir.st explore the centre of the bladder and then turn the beak 
 to each side in turn, giving gentle taps by quickly rotating the instru- 
 ment between thumb and finger. Finally depress the shaft between 
 the patient's thighs, reverse the beak, and explore the bas-fond of the 
 bladder, particularly in cases of enlarged prostate, by gently raising the 
 shaft again. The presence of more than one calculus may be ascer- 
 tained by catching one in the blades of a lithotrite (Fig. 90S), and then 
 
9G8 
 
 SURGERY OF THE BLADDER AND KIDNEYS 
 
 striking the other with the instrument. If the calculus is lodged in 
 a diverticulum, or covered by mucus or blood clot, it may be impos- 
 
 FiG. 907. — Vesical calculus in a boy aged four jears. (Dr. J. P. Hutchinson's 
 case.) Children's Hospital. 
 
 sible to detect it by a sound; and sometimes phosphatic incrustations 
 on the bladder wall are mistaken for a calculus. 
 
 Fig. 908. — Lithotrite crushing stone. (Watson and Cunningham.) 
 
 In most cases skiagraphy is available, and will demonstrate the 
 number and size of all but the softest stones. Cystoscopy is not often 
 
VESICAL CALCULUS 
 
 909 
 
 required, hut if the surgeon possesses a cystoscopc and knows how to 
 use it, no method is so satisl'iictory. 
 
 Treatment. 'The stones must l)c rcmoxcih 'rher(> is no solvent 
 treatment. 
 
 Fig. 909. — Bigclow's evacuating apparatus withdrawing fragmeuls uf calculus 
 from the bladder. (Watson and Cunningham.) 
 
 LitJiotrity and LitJwIajJaxy. — Unless the stones are very hard (mul- 
 berry calculus) they may be broken up into gravel inside the bladder 
 by means of the lithotrite, the operation being known as lithotrity 
 (Civiale, 1824); the fragments are left to be passed spontaneously. 
 It is much better to adopt Bigelow's plan (1878) or immediate evacua- 
 tion of the fragments (litholapaxy) . This is accomplished by gentle 
 kneading of the rubber bulb attached to the evacuating apparatus 
 (Fig. 909), which procedure creates a swirl in the intravesical fluid, 
 as a result of which some fragments are drawn into the bulb at each 
 motion, and by the force of gravity fall into the glass receptacle 
 immediately beneath the rubber bulb. The operation of litholapaxy is 
 
970 SURGERY OF THE BLADDER AND KIDNEYS 
 
 not now ill general use, because the mortality of cutting operations is 
 less than it was when Bigelow's operation was introduced, and because 
 recurrence of stone formation is frequent (IS per cent.j, either because 
 all the fragments are nrrt removed at first, or because urinary obstruc- 
 tion and vesical infection are not relieved. But the primary mortality 
 is very low (under 5 per cent.), and the operation may be done under 
 local anesthesia in very debilitated subjects. It is best reserved for 
 such patients, provided no cystitis is present. 
 
 Fig. 910. — Instruments used in lithotomy: 1. Stone searcher. 2. Grooved staff. 
 3. Lithotomy forceps. 4. Lithotomy scoop (probe gorget at other end). 
 
 Lithotovty. — Though in women small calculi may be extracted by 
 dilating the urethra (the operation is termed lithedasy) , in the large 
 majority of cases of either sex, it is best to remove calculi by an incision 
 into the bladder. In patients under fifty years of age the primary 
 mortality is low; it is easy to ensure the removal of all calculi, efficient 
 drainage is provided when necessary, and prostatic obstruction, if 
 present, may be treated at the same time. Several cutting operations 
 are available, but the suprapubic route is the operation of choice, in 
 either sex and at any age. 
 
 Suprapubic Cystotomy. — This may be done under local anesthesia, 
 but in children a general anesthetic is preferable. The bladder should 
 be distended with from 4 to 6 ounces of saline solution, and the patient 
 placed in the Trendelenburg position. An incision of 2 to 3 inches 
 is made through one or other rectus muscle, close to the median 
 line and extending right down to the pubis, opening the space of 
 Retzius. The fingers then draw upward the prevesical fat and 
 fold of peritoneum. The bladder is recognized by its bluish color. 
 Large veins should be avoided. A traction suture is inserted in 
 the bladder wall on each side of the site of the propo.sed vesical 
 incision, and the bladder is then opened by the knife which cuts 
 downward toward the pubis. Before all fluid escapes the finger is 
 inserted and the cavity of the bladder explored. The stone is then 
 removed with suitable forceps. Be careful to remove all the stones 
 and not to overlook one in a diverticulum. (If indicated the prostate 
 may now be removed. See p. 1038.) If there is no cj'stitis (which is 
 seldom the case) the bladder incision may be closed completely, care- 
 
/AjrA'/A'.s OF rinc in. adder 971 
 
 l'ull\ in\ (Ttiiij^ its cd^cs so as to prcxciit |)rolii])s(' ol" mucous ni('nil)raiH\ 
 hi (loiihttul cases it is hcttcr to drain l)y iiiscrtin<^ a tube as in tiic opera- 
 tion of cliolecystostoniy (p. \Y.M)), carefully inx-crtin^ the mucous mem- 
 hraiie. In all cases, a small wick of gauze should he placed in the space 
 of Rct/ius. The vesical tube should be allowed to come away of itself, 
 which it usually docs in the second week. The urinary fistula is then 
 encouraged to close. 
 
 Perineal Lithotoviy. — Tiie lateral operation, in which the l)ladder is 
 o])ened through the membranous and prostatic urethra by an incision 
 w hich i)asses from the base of the scrotum outward to the left ischio- 
 rectal fossa, is seldom employed now. A grooved stafi" (Fig. 01 Oj in 
 the urethra is used as a guide in making tlie incision. The primary 
 mortality is low, especially in children, but the deep incision is apt to 
 injure the ejaculatory ducts, only calculi of less than 2 inches in 
 diameter can be removed, and it requires considerably greater skill 
 than the suprapubic operation. Median yerineal Hlhoiomii has a much 
 higher mortality, and affords still less room. 
 
 Foreign Bodies. — Foreign bodies in the bladder may be removed 
 by experts with the operating cystoscope. In the hands of the general 
 surgeon more success attends suprapubic cystotomy; though small 
 objects may be successfulh' extracted by a perineal urethrotomy 
 incision (p. 1022). 
 
 Injuries of the Bladder are rare. Most frequent are ruptures. 
 These may involve the intraperitoneal or the extraperitoneal surfaces, 
 or both. They occur most often in men, and the chief predisposing 
 cause is alcoholic intoxication: this increases the quantity of urine, 
 obtunds the sensibilities so that an overloaded bladder is neglected, 
 and renders its subjects quarrelsome, helpless, and prone to injury. 
 The chief symptoms are abdominal pain and bloody anuria: the patient 
 desires to urinate, but only a little blood is passed. Extraperitoneal 
 rupture frequently complicates a fracture of the pelvis, and is difficult 
 to distinguish from rupture of the urethra on the pelvic side of the 
 triangular ligament (see p. 1017). In intraperitoneal rupture peri- 
 tonitis soon follows, as the urine seldom is aseptic. The diagnosis 
 should be made before this time by means of physical examination. 
 A catheter should be passed (extreme asepsis!) and any bloody urine 
 present should be evacuated. Then at least one quart (in the adult) 
 of sterile saline solution should be injected, unless the development 
 of a suprapubic mass corresponding to the unruptured bladder appears 
 sooner. Then this fluid should be withdrawn. Unless all the injected 
 fluid is regained, it is evident that it has passed out of the bladder. If 
 more fluid than was injected into the previously emptied bladder is 
 returned, it is evident that fluid is being drained from the peritoneal 
 cavity. In either case, the abdomen should be opened, the rent in 
 the bladder sutured (inverting its edges with sero-serous sutures), 
 and the peritoneal cavity drained. It is also well to leave a catheter 
 in the bladder, draining it through the urethra. The mortality is 
 about 2.3 per cent. (Ashhurst, 1906). 
 
972 SURGERY OF THE BLADDER AXD KIDXEYS 
 
 SURGERY OF THE KTONEYS. 
 
 Anomalies of Form and Position. — One of the commonest congenital 
 malformations of the kidney is the so-called horseshoe kidney. Here 
 the two organs are fused together, usually at their lower poles. This is 
 found once in about a thousand cases. It increases the difficulties of 
 diagnosis and treatment of kidney lesions. The ureters may or may 
 not be normal in such cases; but even with normal kidneys al)normali- 
 ties of the ureters are not very rare. The commonest abnormality is 
 the existence of two ureters to the same kidney; each may spring from 
 a separate renal pelvis, or both may leave the same pelvis. The diag- 
 nosis of such conditions sometimes is made before operation by skiag- 
 raphy after catheterization of the ureters with instruments impervious 
 to the .r-ray or after distending them with collargol. Anomalies of the 
 blood-supply of the kidneys are frequent. The most important are 
 extra arteries to the upper or lower pole of the kidney, or an artery 
 which crosses in front of the ureter, and which may be a cause of 
 hydronephrosis by intermittent pressure or by causing kinking of the 
 ureter. The kidney- may be congenitally misplaced in almost any posi- 
 tion in the abdomen, btit this is very rare. 
 
 Nephroptosis, or Movable Kidney, usually is regarded as an acquired 
 condition, but some investigators have found it in a definite propor- 
 tion of patients in early infancy. It is more common in women than 
 in men (4 to 1), and is predisposed to by anything which increases 
 the capacity of the lower abdomen (repeated pregnancies, removal 
 of pelvic tumors), or which diminishes the room beneath the diaphragm 
 (tight lacing, scoliosis), and which at the same time causes relaxation 
 of the normal support of the kidney (general poor health, or wasting 
 diseases with absorption of fat). Nephroptosis usually is present in 
 cases of visceroptosis (p. S98), but frequently exists alone. It is more 
 common on the right than the left side, but both kidneys often are 
 affected. 
 
 Symptoms. — The patients usually are thin, long-waisted, run-down 
 women from thirty to fifty years of age. In most cases the condition 
 is unknown to the patient, and is discovered as an incident in an 
 abdominal examination. When symptoms exist the chief complaint 
 is weakness and dragging sensations in the loin; but no acute s\'mptoms 
 arise unless the kidney becomes twisted on its pedicle, resulting in sud- 
 den congestion from ^-enou3 stasis or blockage of the ureter with tem- 
 porary hydronephrosis. Such acute attacks are known as Dietl's crises 
 (18()4). The diagnosis depends on recognizing by palpation the movable 
 kidney. Three grades are recognized: (1) When the kidney is merely 
 palpable; (2) where it is movable; and (3) where it is floating. Examina- 
 tion is conducted with the patient recumbent, and the thighs flexed 
 to relax the abdominal muscles. The stirgeon places one hand beneath 
 the loin, and presses downward firmly but gently with the other hand 
 in the flank, until the two hands are approximated. Then when the 
 patient takes a long breath the lower pole of the kidney, if it is palpable. 
 
INFECTIONS OF I'lIF KIDNEYS 5)73 
 
 is forced down against the examining liand. If the kidney is trnly 
 iiKii'dhlc it can l)e felt also when the patient stands and leans forward, 
 resting her hands on tlie edge of the hed. 'J'he examiner now stands 
 behind her, and works his hand gently npward from the iliac fossa 
 toward the flank; whereupon, during deep inspiration, a movable mass 
 may be recognized, which slijis back to the loin, during exi)iration. 
 A jUmfiiuj kidney can almost be grasped in the fingers, and may be 
 found in the iliac fossa or the pelvis. Fixation of such a floating 
 kidney in abnormal position, by adhesions or otherwise, constitutes 
 a dislocated kidney. This is a very rare condition. A Dietl's crisis 
 is recognized by its occurrence in a patient with a floating or movable 
 kidney, by the sudden increase in size of the tumor, by the attending 
 constitutional disturbance (nausea, vomiting, shock, perhaps chills 
 and fever), by the absence of intestinal or peritoneal symptoms, and 
 by prompt subsidence of symptoms when the kidney becomes un- 
 twisted on lying down or by manipulation. Subsequently microscopical 
 study of the urine may show blood. 
 
 Treatment. — If no symptoms exist, no treatment is indicated beyond 
 building up the patient's general health. If symptoms are present 
 they often are relieved by a rest-cure, with forced feeding, or by the 
 application of an abdominal belt such as was advised for cases of 
 pendulous abdomen. It rarely is desirable to use a special pad o\ev 
 the kidney. If recurrent attacks of torsion occur, or if palliative 
 treatment fails to relieve chronic symptoms which are undoubtedly 
 due to the mobility of the kidney, this organ may be fixed in its proper 
 position by operation (nephropexy). Various methods are employed. 
 In all it is important to secure the kidney in a position as nearly normal 
 as possible, avoiding particularly excessive rotation of the organ in 
 any direction. One of the most satisfactory operations is to incise 
 the capsule along the convexity of the kidney, to peel the capsule 
 back in two leaves, and to suture these to the lumbar aponeurosis 
 (Edebohls, 1901). The lumbar wound is closed in layers without 
 drainage. Another method is to support the kidney in the depths of 
 the wound by two slings of gauze, one under each pole; the gauze is 
 left in place for a week or ten days, and the adhesions which result in 
 the extensive granulating wound are supposed to hold the kidney in 
 place. Da Costa employs slings each of which is made by suturing 
 together with catgut, end-on, two pieces of gauze, the sutured portion 
 is placed around the kidney, and when the catgut has been absorbed, 
 the ends of the slings are easily removed. 
 
 Infections of the Kidneys arise in most cases either from the blood- 
 stream or as ascending infections from the bladder or genitalia. 
 
 Hematogenous Infections. — The kidneys receive from the body and 
 discharge through the urine great quantities of toxins, and in many 
 cases large numbers of bacteria (bacteriuria, p. 964). If the resistive 
 power of the kidneys is weakened (previous renal disease, urinary 
 obstruction, trauma, etc.) or if the toxins or bacteria are of extra- 
 ordinary virulence, inflammation of the kidneys (nephritis) results. 
 
974 SURGERY OF THE BLADDER AND KIDNEYS 
 
 There are various forms of nephritis, which are best classed as acute 
 and chronic. Only some of these need concern us here. 
 
 Cases of toxic nephritis due to mineral poisons, and those cases due 
 to toxemia (as in scarlatina, diphtheria, influenza, etc.) or auto- 
 intoxication (as in chronic intestinal stasis, pregnancy, etc.), may be 
 acute but frequently are chronic from the beginning, and usually 
 are cared for by the physician. Of late years, however, it has become 
 possible to relieve some of these patients by operative means. Punc- 
 ture of the kidney or incision of its capsule was advocated by R. 
 Harrison in 1897, by Ferguson and Edebohls in 1S99, and the latter 
 in 1901 reported a number of cases in which he had practised decap- 
 sulation of the kidneys. By stripping the capsule from the contracted 
 and sclerosed kidney its nutrition is improved by relief of tension and 
 perhaps by development of collateral circulation. There is no doubt 
 that in many cases vast improvement occurs : the amount of the urine 
 increases, the edema and ascites vanish, casts disappear from the 
 urine, and previously bed-ridden patients are enabled to resume a 
 certain degree of activity. In favorable cases this improvement has 
 lasted several years, though evidences of chronic nephritis persist. 
 In other patients, however, no improvement occurs or the state is made 
 worse. The operation is still on trial. The kidney is exposed as for 
 other kidney operations (p. 985), it is brought into the wound, and 
 its capsule is incised along the convexity; the flaps of the capsule are 
 then stripped off the organ to the hilum on each side, and are excised; 
 the kidney is replaced and the wound closed without drainage, but 
 not too tightly. It is better to postpone operation on the second 
 kidney for a week or ten days. Brewer recommends the operation 
 in cases of severe acute nephritis, following the exanthemas, etc. 
 
 Septic Nephritis. — What are commonly recognized as surgical 
 infections of the kidney, of hematogenous origin, are cases of acute 
 nephritis due to septic embolism. In a large proportion of cases only 
 one kidney (usually the right) is affected, and the lesions vary from 
 hemorrhagic infarcts (which soon heal, leaving minute cicatrices) 
 to difl'use suppuration. Several foci of suppuration may coalesce and 
 form distinct abscesses. Extension to the pelvis of the kidney, causing 
 ■pyelitis, is frequent; extension to the fatty capsule of the kidney and 
 surrounding structures (perinephritis) is less usual. In cases where 
 pelvis and kidney are diffusely involved {x)yeh-nephritis) it may be 
 impossible to distinguish the pathological changes from those caused 
 by an ascending infection. 
 
 Symptoms. — The recognition of acute unilateral hematogenous 
 infection of the kidney is due mainly to the work of Brewer. Over 
 80 per cent, of the cases occur in women, frequently as a sequel of 
 some known general infection (pneumonia, tonsillitis, furunculosis, 
 etc.). The onset and course of the disease may be very acute, sub- 
 acute, or comparatively mild. The severe cases usually begin with a 
 chill, temperature of 104° or lOS"" F., rapid pulse and high leukocytosis. 
 From the first the symptoms of toxemia are marked, and the local 
 
INFECTIONS OF THE KIDNEYS 975 
 
 coiulitioii iii:i.\- ])«> ()\tTl()(»ke(l, the disease resenil)lin^ jjerhaps iriHiiciiza, 
 lobar piieumoiiia, or one of tlie exaiithemas. Suhsequeiitly attention 
 is (lireeted to the kidney region by pain and discomfort in the abdomen 
 or flank, and these may be mistaken for signs of cholecystitis or 
 aj)i)en<li(itis. ( "()ni])ensatory action of the healthy kidney may obscure 
 urinary changes (red-blood cells, albumin, ])us) unless especially looked 
 for. "The one pathognomonic sign present in all cases," adds Brewer, 
 " is a marked unilateral costovertebral tenderness." 
 
 Trr(ifnirnf.~\n the severe cases, with high temperature and pro- 
 gressive toxemia, nephrectomy should be done without unreasonable 
 delay ; death is the almost invariable result of such delay or of j)alliative 
 operations. In the milder cases, which Brewer describes as those 
 where the temperature begins to fall within forty-eight hours, decap- 
 sulation of the kidney may be done, or nephrotomy if there is evidence 
 of much tension or localized suppuration. In the mildest type, where 
 the diagnosis may be uncertain, medical treatment may be persisted 
 in^ and any chronic pyelonephritis which remains may be subjected 
 to appropriate surgical treatment subsequently. 
 
 Ascending Infections. — Ascending as well as hematogenous infection 
 is predisposed to by previous renal disease (especially renal calculus) 
 or the occurrence of trauma; but even in such circumstances it rarely 
 occurs unless there is obstruction to the urinary outflow\ In women, 
 pressure from pelvic tumors or the gravid uterus is a cause of urinary 
 obstruction which leads not infrequently to ascending kidney infec- 
 tion. In men such obstruction is due in most instances to enlarge- 
 ment of the prostate or stricture of the urethra. Back pressure of 
 urine within the bladder first compresses the ureteral orifices, damming 
 the urine back into the ureters and kidneys; inflammatory infiltration 
 of the bladder wall from cystitis may impair the sphincteric action 
 of the ureteral orifices; and if extreme dilatation of the bladder occurs 
 the ureteral orifices may become constantly patulous, by the approxi- 
 mation of their course through the bladder-walls to a straight line. 
 It is probable also that infection extends up the Avails of ureters to 
 the kidney pelvis, and thus produces pyelitis and pyelo-nephritis, 
 which are the usual results of obstruction in the presence of infection. 
 In some cases the ureters appear unaffected, but in most they are 
 dilated, pouched and perhaps strictured. The pyelo-nephritis arising 
 from ascending infection is commonly spoken of as surgical kidney. 
 The renal cortex is thinned, the pelvis enlarged, and the kidney sub- 
 stance is riddled with al)scesses of various sizes. 
 
 Symptoms. — Surgical kidney is more frequent in the aged than in 
 the young, and occurs very much oftener in men than in women. 
 It may be acute or chronic, but as acute attacks tend to be prolonged 
 by chronic symptoms, and as the chronic condition frequently is 
 interrupted by acute attacks, the symptomatology is best considered 
 together. The onset usually is acute, and often follows exposure 
 to cold or wet, the passage of a catheter, sounding for .stone, or dilata- 
 tion of a urethral stricture. The patient has a chill, is nauseated, his 
 
*)7() SURGERY OF THE BLADDER AND KIDNEYS 
 
 temperature rises, and for a few hours he may be very ill. In many 
 cases these symptoms cannot be distinguished from those of so-called 
 urethral fever (p. 102()), but the diagnosis of pyelitis is probable if 
 fever continues, and becomes almost a certainty if there is a dull ache 
 in one or both loins and if an enlarged, tender kidney can be palpated. 
 The urine contains pus, sometimes blood, and usually is alkaline. 
 The pus settles slowly to the bottom of the receptacle, whereas the 
 pus of cystitis settles very quickly. 
 
 One or both kidneys may be affected. If only one is affected and 
 the ureter is completely blocked, the urine may be fairly normal, while 
 the patient's condition will grow worse; on the other hand, if free 
 drainage of the kidney is present the patient may feel quite comfortable 
 in spite of the infected character of his urine. In the average chronic 
 case, so long as the kidney drains freely, the patient may be little 
 troubled by subjective symptoms unless an exacerbation occurs from 
 renewed irritation of the urinary passages, or indiscretions in diet, etc. 
 Recurrence of acute attacks is common, as the kidney, unlike the 
 bladder, has no great tendency to sterilize itself spontaneously. 
 
 Treatvieni.— In the acute cases put the patient to bed, and ensure 
 free drainage of urine from the bladder by an inlying catheter if neces- 
 sary. Keep the patient on a milk diet, and make him drink plenty 
 of water. Give 15 grains of urotropin three times daily. Treat 
 threatening uremia by diuretics, cathartics, sweating, and if necessary 
 venesection. If the urine is nearly normal, or anuria is present, and 
 the kidney enlarged and tender, nephrotomy or rarely nephrectomy 
 may be required; but whenever possible radical operation should be 
 postponed until the acute attack subsides. When the chronic stage 
 is reached, radical treatment of the obstructing cause (stricture, 
 enlarged prostate, etc.) may succeed in curing the pyelitis. Before 
 nephrectomy is done, in any case, the functional capacity of the other 
 kidney must be proved adequate (p. 961). 
 
 Hydronephrosis. — This is hydrops of the kidney due to urinary 
 obstruction, in the absence of infection. The condition may be unilat- 
 eral or bilateral. Causes of unilateral hydronephrosis are recurrent 
 torsion of the ureter by the vagaries of a movable kidney; impaction 
 of a stone in the ureter without complete blocking of the canal; or 
 stricture of the ureter. Bilateral hydronephrosis is due to obstruction 
 of both ureters, either directly, as by a tumor of the bladder involving 
 both ureteral orifices, pressure of a pelvic tumor, etc., or indirectly by en- 
 largement of the prostate, stricture of the urethra, etc. The symptoms 
 occur as a sequel to those due to the obstructing lesion; the kidney 
 becomes enlarged and may reach an immense size. If temporary 
 relief of the obstruction occurs, the accumulated urine is discharged, 
 with polyuria and disappearance of the tumor. This, however, may 
 soon refill {intermittent hydronephrosis). 
 
 Treatment. — Treatment comprises removal of the obstruction when 
 this is possible. A movable kidney may be fixed; a stone in the ureter 
 removed; a stricture of the ureter treated by dilatation, ureteroplasty 
 
NErnuourn/ASis 977 
 
 (analogous to pyloroplasty) or hy resection arul eiul-to-erul suture; 
 a pel\ic tumor may he excised. Finally, if no obstruct ion can be 
 found, or if it camiot he remo\('d, and the kidney is fun< tionless, 
 nephrcctoinx may Ix* done. 
 
 Pyonephrosis. I'yoneijhrosis occurs as tiie end-result of pyelo- 
 ne|)hritis, or it may he due to the infection of a j)re("'.\istinf,' hydro- 
 nejjhrosis. If the other kidney is functionally sufficient, nephrectomy 
 sliouid he done. Nephrotomy with drainaji;e rarely i.s beneficial, and 
 in most eases nephrectomy and death are the only alternati\es, and 
 death may follow nephrectomy. 
 
 Perinephric Abscess. — This is suppuration in the fatty capsule of 
 the kidney. 1 have already mentioned the occurrence of perineph- 
 ritis as a sequel, of septic nephritis; and though perinephritis often 
 results in sup])uration there are many other causes for perinephric 
 abscess; hence the term peri nephritic abscess should not be used, 
 the kidney being at fault only in about one-fifth of the cases (M. B. 
 Miller, 1909). In most cases the source of infection is in the lower 
 genito-urinary tract, and extension to the j)erirenal tissues occurs 
 along the lymphatics. Trauma may be a predisposing cause. Pul- 
 monary complications are frequent. 
 
 Symptoms. — Symptoms often are subacute in onset, and the patient 
 may not be laid up until a week or more has elapsed. He complains 
 of local pain and tenderness, walks guardedly, with his body bent 
 toward the affected side; and the thigh is slightly flexed; there is local- 
 ized muscular rigidity, and a tender spot between the twelfth rib and 
 iliac crest posteriorly. Later there may be moderate or high elevation 
 of temperature; leukocytosis usually is high (average is 25,000) ; and still 
 later distinct evidences of suppuration develop. Sometimes, however, 
 the onset is very acute, wdth chill, high fever, and extreme prostration. 
 The diagnosis is not always easy, even if the condition is kept in mind. 
 A source of infection should be looked for. Confusion wnth a lumbar 
 abscess, due to Pott's disease of the spine, should not arise unless such 
 a cold abscess is secondarily infected and signs of spinal involvement 
 are absent. 
 
 Treatment. — Treatment consists in evacuating the abscess by a 
 lumbar incision; and this should not be ])ostponed if the symptoms 
 are acute, even if the diagnosis is uncertain. 
 
 Nephrolithiasis or Renal Calculus. — The urine of many persons 
 may contain crystalloids in abnormal amount, yet so long as they are 
 held in solution by the action of colloids, no stone will be formed. 
 If, however, the crystalloids are present in excess of the power of the 
 colloids to hold them in solution by means of what is known as adsorp- 
 tion, then the crystalloids (uric acid, acid urates, calcium oxalate, etc.) 
 go out of solution and are deposited on the colloids as a matrix. If 
 the colloids are what are known as reversible colloids, such as mucin, 
 both they and the mineral deposited on them may be redissolved by 
 more water. If, however, the colloid is irreversible, such as fibrin, 
 it cannot be re-dissolved. The colloid mostly concerned in the forma- 
 62 
 
978 SURGERY OF THE BLADDER AND KIDNEYS 
 
 tion of urinary calculi is believed to be fibrin; and as this is a product 
 of inflammation and infection, it is not unreasonable to suppose that 
 calculi may form as the remote result of an attenuated infection of 
 the urinary tract, much as gall-stones are formed in the biliary tract. 
 But the influence of infection in these cases has not been proved, 
 and it is customary to regard such calculi (uric acid, oxalate of lime; 
 rarely cystin, etc.) as inimary calculi, in contradistinction to those 
 undoubtedly the result of bacterial infection of the urinary tract, 
 which are termed secondary calculi. These latter usually are composed 
 of triple phosphates and result from bacterial decomposition of the 
 urine. Phosphatic deposits may occur as laminations on primary 
 calculi, as concretions on the mucous membrane lining the urinary 
 tract, or as distinct calculi. 
 
 Renal calculus is most common between twenty and forty years of 
 age, aflfects men somewhat oftener than women, and the right kidney 
 a little oftener than the left. Both kidneys are involved in from 
 20 to 50 per cent, of cases. The prevention of calculus formation 
 concerns the physicians; when stones have formed in the kidney the 
 case becomes surgical. 
 
 The classification of urinary concretions as sand, gravel, and calculi, 
 has already been mentioned (p. 967). Sand may be productive of no 
 definite symptoms; gravel gives rise to repeated attacks of renal colic 
 as the small stones pass into or through the ureter; while a calculus 
 so large as to be relatively immovable may be symptomless. The 
 smaller the calculi, as a general rule, the greater is their number and 
 the more apt are they to produce symptoms. 
 
 Symptoms. — These may be divided into those of simple nephro- 
 lithiasis and those of complications of the disease, such as renal colic, 
 hydronephrosis, pyelitis, and its sequels. 
 
 In simple nephrolithiasis (which corresponds to simple cholelithiasis) 
 the stones remain in the kidney and infection is absent. There may 
 be no symptoms to call attention to the kidney. What symptoms the 
 patient complains of usually are referred to the bladder, and are the 
 effect of passage of urine altered in quality or quantity. Especially 
 valuable as suggestive of renal disorder is the occurrence of blood in the 
 urine, usually in microscopic amount. It may be present only after 
 the patient has been up and about, and may disappear if he lies quiet 
 in bed. Unless secondary infection occurs, or unless the kidney is 
 unduly movable, and therefore liable to congestion or to hydro- 
 nephrosis, it is unusual for much pain to be felt in the kidney region 
 itself or for macroscopical hematuria or pyuria to occur. But sometimes 
 complaint is made of a dull ache in the lumbar region, and quite 
 frequently there is tenderness on pressure here, or over the lower pole 
 of the kidney in the flank. Sometimes the kidney is palpably enlarged. 
 Murphy places special reliance on fist percussion over the lower ribs, 
 using one hand as plessimeter and thumping it with the other fist 
 as plessor. He claims that in the presence of a renal calculus this 
 always produces severe pain. Subjective symptoms, such as pain 
 
NEPIIROLITIIIASIS 979 
 
 over the kidney, frequently disappear as soon as the patient goes 
 to bed; and after his athnission to a hospital ward tlie diagnosis may 
 seem doubtful. The a:-ray is of inestimable value in the diagnosis of 
 renal calculus, but unfortunately it may be difficult, or impossible, to 
 secure a skiagraj)h which will show calculi of pure uric acid (Fig. 911). 
 Fortunately few calculi are composed of uric acid or urates without 
 some admixtures of other salts. No plate should be considered satis- 
 factory unless the shadow of the psoas muscle is clearly visible. Con- 
 fusion arises from defects in the plate, shadows of fecal concretions, 
 and, in the case of ureteral stone, from those of phleboliths, calcifica- 
 tion around ligatures left at previous pelvic operations, etc. The 
 functional capacity of the other kidney (p. 9G1) should be ascertained 
 in everv case of renal calculus. 
 
 Fig. 911. — Shadows cast in a radiogram l)y different renal calculi: on the left, phosphatic; 
 in the centre, uric acid; on the right, oxalate of lime. (Rothschild.) 
 
 , Renal colic is the most frequent symptom of complicated cases of 
 nephrolithiasis, but it may be caused by other factors than the passage 
 of a calculus through the ureter. The symptoms are the same as in 
 cases of Dietls's crisis (p. 972), but in the latter condition the kidney 
 always is movable, which is not often the case in nephrolithiasis. Pain 
 is referred along the course of the ureter, into the testicle, and down 
 the thigh, and sometimes to the end of the penis. The pain usually 
 begins and ends suddenly; but if the stone is impacted in the ureter 
 the pain ceases gradually and light attacks of colic recur often. There 
 may be nausea and vomiting, but there seldom is much constitutional 
 disturbance, unless the kidney is infected, wdien the symptoms of 
 pyelitis, etc., arise. These have already been considered. During 
 the continuance of the colic the urine may be diminished or entirely 
 suppressed; crebruria, with tenesmus, is frequent, and blood usually 
 is found in the urine. 
 
 Diagnosis of Nephrolithiasis. — This is not certain unless the stones 
 are seen in a skiagraph (Fig. 912); and even then, as noted above, 
 sources of error are not infrequent. If gravel has been passed, and 
 colic persists, it is a fair inference that other stones remain; and the 
 diagnosis is very probable if repeated colic occurs, with hematuria 
 
980 SURGERY OF THE BLADDER AND KIDNEYS 
 
 and occasionally pyuria, with symptoms of pyelitis. The chief con- 
 ditions from which renal calculus must be distinguished are biliary 
 colic, appendicitis, and intestinal obstruction. The diagnosis of these 
 has alread\' been considered. 
 
 Fig. 912. — Skiu^iraph of ralculus in kidney. The faint sliadow of the psoas 
 muscle is barely visible. Episcoi)al Hospital. 
 
 Treatment. — If the stones are shown b>' skiagraphy to be merely 
 gravel, and if such haxe already been passed successfully, it is sometimes 
 advisable to trust to medical treatment to prevent the formation of 
 other calculi, and to allow the patient to pass such as already exist 
 per vias naturales (Fig. 913). Any stone too large to be passed 
 requires removal by operation ; especially is this true when pyelitis is 
 present and fails to clear up under palliative treatment. 
 
 If the stones lie loose in the kidney pelvis, a fact which cannot be 
 determined before the kidney is exposed, they should be removed by 
 pyeloiomy; if they are fixed in the cortex, neyhrotomy (nephrolith- 
 
CALCULUS ANURIA 981 
 
 otoiiiy) should he iUnw. Those operations are deserihed at p. 9(S(). If 
 the presenee of ealeiih is uiu'ertaiii it is better to incise tlie kiihiey 
 sufficiently to explore its interior than to endeavor to locate the stone 
 by "needlin<,^" the kidney. In all cases a sound or ureteral catheter 
 should be passed down the ureter to the bladder, to make certain 
 that no ol)stru('ti()n has been overlooked. 
 
 Vn;. 91.S. — Rciiiil calculus of uric acid passed by urethra. (Scale in inches.) 
 Orthopii'dic Hos|jifal. 
 
 Ureteral Calculus. — The .r-ray has shown that calculus is more 
 frequent in the ureter tfian in the kidney (C. L. Leonard). In nearly 
 afl cases the stone has descended from tlie kidney. It lodges by pref- 
 erence (1) Just below the renal pelvis; (2) at the brim of the true pelvis; 
 or (3) just outside the bladder walk Blockage of the ureter in the 
 first position causes symptoms similar to those of renal calculus; in 
 the last position, those resembling cystitis. Stones arrested at the 
 brim of the pelvis frequently are mistaken for chronic appendicitis, 
 and the appendix is removed in vain. 
 
 Complete blockage of the ureter may bring on calculous anuria. 
 This may be due to the functionally useless state of the second kidne\'; 
 to blockage of both ureters at once; to the existence of only one kidney, 
 or of a horseshoe kidney with a single ureter; or to what is called 
 "reflex inhibition" of the healthy kidney. Unless relieved by opera- 
 tion, calculous anuria usually terminates in uremia and death; occa- 
 sionally death occurs suddenly without uremic symptoms. The free 
 interval varies from one to sixteen days, but rarely is it longer than 
 three or four days. 
 
 Treatment. — A stone in the upper part of the ureter often can be 
 worked backward into the kidney pelvis; if not, it must be exposed 
 by enlarging the lumbar wound, and removed by direct incision of the 
 ureter {ureterolithotomy). If in the middle portion of the ureter, 
 the stone is best exposed extraperitoneally through a McBurney or 
 similar incision. As the peritoneum is stripped up from the iliac fossa, 
 it carries the ureter with it. Gibbon places a finger inside the peri- 
 toneal cavity to aid in bringing the ureter into the wound. A stone 
 very near the bladder may be reached extraperitoneally by the 
 suprapubic route (C. L. Gibson) ; vaginal and perineal operations are 
 less satisfactory. A calculus in the intramural part of the ureter may 
 be extracted by suprapubic cystotomy, or even by means of the 
 operating cystoscope. 
 
 Calculus anuria requires active treatment to prevent uremia; hot 
 baths, sweating (pilocarpin) ; morphin and atropin to allay pain and 
 
982 SURGERY OF THE BLADDER AND KIDNEYS 
 
 spasm. Unless the anuria is relieved within thirty-six or at the most 
 forty-eight hours, operation should be done. There is no time to 
 undertake an elaborate search for the site of obstruction in the ureter; 
 so unless this is known (when ureterolithotomy by the proper route 
 is indicated) the diseased kidney should be exposed and drained, the 
 radical operation being postponed until convalescence. 
 
 Tuberculosis of the Kidney. — Tuberculosis of the genito-urinary 
 tract usually develops first in the kidney (66 per cent, of cases), or the 
 epididymis (30 per cent.) ; in a few cases it appears first in the Fallopian 
 tubes, the prostate, testis, uterus or seminal vesicles (Watson and 
 Cunningham). In nearly all cases the infection is blood-borne and 
 is secondary to a focus elsewhere in the body (bronchial or mesenteric 
 lymph nodes). The bladder, as pointed out at p. 965, scarcely ever 
 is the first portion of the genito-urinary tract to be invaded, and as a 
 consequence ascending tuberculous infection of the kidney is exceed- 
 ingly rare. Secondary pyogenic infection, however, frequently ascends 
 from the bladder and causes rapid disintegration of the tuberculous 
 kidney. 
 
 In most cases only one kidney (the right and left about equally) 
 is affected at first, and the other kidney may remain intact for a long 
 time. The lesions commence in the cortex, but the pelvis is invaded 
 when rupture of the caseous foci occurs. The ureter may remain 
 healthy long after the infection has secured a foothold in the bladder. 
 
 The disease is most frequent in early adult life, and the sexes are 
 about equally affected. At the time patients come to operation the 
 disease is still confined to one kidney in more than half the cases, 
 and even at autopsy the second kidney is free in about one out of 
 three cases. In the large majority of cases of bilateral disease the 
 second kidney is only very slightly involved. 
 
 Symptoms. — There are both constitutional symptoms characteristic of 
 a tuberculous lesion, and local symptoms referable to the urinary tract. 
 Among the former may be mentioned afternoon pyrexia, nervousness, 
 sleeplessness, anorexia, and loss of weight. Though the patient seems 
 ill, no definite cause is apparent. After weeks or months, urinary 
 symptoms appear. At first these are referred to the bladder; 
 the urine is passed frequently; its quantity ,is increased, and its 
 specific gravity lessened ; it contains pus and microscopical amounts of 
 blood. Frank hematuria is rare. Vesical irritability may be extreme 
 before the tuberculous lesion has spread to the bladder. Secondary 
 pyogenic infection of the kidney causes hectic fever, night sweats, 
 emaciation, and rapid loss of strength. Not until this stage is reached 
 is the acidity of the urine lost. 
 
 Diagnosis. — Vesical symptoms should not divert attention from the 
 kidney. Pus in the urine does not necessarily mean cystitis. In cys- 
 titis the urine almost always is alkaline; but in renal tuberculosis it 
 remains acid until pyogenic infection is far advanced. Occurrence 
 of remissions in the severity of the symptoms is highly characteristic 
 of tuberculosis, but is unusual in renal calculus. In the latter, exacer- 
 
TUMORS OF THE KIDNEY 983 
 
 bation of syinptonis usually follows exercise; but in renal tuberculosis 
 this constant relation of cause and efl'ect is not seen. Renal calculus 
 usually may be excluded by skiagrai)liy. In tuberculosis the tempera- 
 ture chart (e\en in the absence of pyogenic infection) should recuse 
 suspicion of tlie nature of the infection. The hypodermic use of tuber- 
 culin and inoculation experiments with the centrifugated urinary 
 sediment, are valuable aids in diagnosis. Cystoscopy usually reveals 
 appearances around the ureteral orifice on the diseased side which 
 are considered by experts highly characteristic. Ureteral catheteri- 
 zation is the surest way of determining the healthy condition of 
 the second kidney. In many cases inoculations and examinations 
 of the urine for tubercle bacilli have to be repeated on se\eral 
 occasions, as the results are not always constant. 
 
 Treatment.— ]\Iost surgeons are in accord in recommending removal 
 of the diseased kidney as the only hope of cure; even if the other kidney 
 is slightly diseased, the tuberculous process may become latent in it 
 after the more diseased organ has been removed. The excellent efi'ect 
 of nephrectomy on vesical tuberculosis has already been mentioned 
 (p. 905). The immediate mortality of nephrectomy for tuberculosis 
 is from 5 to 10 per cent.; and about 26 per cent, of patients are cured 
 of the disease and remain well for three years or longer. In most 
 others great improvement occurs. But if the second kidney is incom- 
 petent, nephrectomy should not be done, and hygienic treatment alone 
 must be employed. If pyonephrosis is present, relief may be afforded 
 by nephrotomy and drainage, if nephrectomy is contraindicated. 
 
 Tumors of the Kidney. — These are conveniently classed as solid 
 tumors and cysts. 
 
 Solid Tumors of the Kidney. — Hypernephroma is the commonest 
 (p. \'1~). Other solid tumors are sarcoma and carcinoma. Benign 
 solid tumors are very rare. Solid tumors occur oftenest in adult life, 
 especially from forty to sixty years of age; but sarcomas, embryonic 
 tumors and tumors of the adrenal gland are seen in children. 
 
 The physical signs of all these solid tumors are much the same, 
 and have been considered under the differential diagnosis of enlarge- 
 ments of the spleen (p. 953 j. Hypernephroma may grow to immense 
 size, but the other malignant tumors kill before they reach great size. 
 Symptomatic varicocele and severe referred pain are usual results, and 
 ascites is an unusual result of pressure by kidney tumors. The chief 
 characteristic, apart from the presence of a tumor, is hematuria, which 
 often is painless, usually is profuse, and occurs without vesical S}mp- 
 toms. Bright red blood is passed from the urethra when the patient ex- 
 pects urine. Bleeding may be so profuse as to produce faintness, recurs 
 at irregular intervals, and is not made worse by exercise as is the less 
 marked bleeding which attends renal calculus. If the ureter is blocked 
 by a clot the urine is clear, but diminished in amount, and severe pain 
 may be felt in the loin. When hemorrhage occurs and back pressure 
 on the kidney is relieved the patient may feel better. Tumor of the 
 adrenal sometimes may be distinguished from tumors of the kidney 
 
984 
 
 SURGERY OF THE BLADDER AXD KIDXEYS 
 
 proper b>" attention to certain details: it is most frequent in children, 
 and anorexia, listlessness, loss of weight and strength may be noted 
 weeks or months before the tumor is discovered; the tumor grows 
 beneath the diaphragm, pushes the kidney down, causes early referred 
 pain and paresthesia, and sometimes is accompanied by bronzing of 
 the skin and precocious puberty; hematuria is very rare. The skeleton 
 always should be examined for metastases. 
 
 Prognosis. — H\"pernephroma generally leads to death within three 
 of four years. Sarcoma and carcinoma terminate fatally within a 
 year or less, as do tumors of the adrenal in children. 
 
 Treatment. — Nephrectomy should be done whenever possible. 
 If the growth is large the transperitoneal route is the best. The 
 immediate mortality of operation is about 25 per cent, and most 
 patients wlio sur\-i\e succumb to metastases within two years. 
 
 Cystic Tumors of the Kidney are rare and of little surgical interest. 
 Polycystic disease sometimes appears to be hereditary; it is seen 
 oftenest in early infancy or in middle life; usually both kidneys are 
 affected, and hence nephrectomy which other'«-ise would be proper, 
 is contraindicated. Simple serous cysts of the kidney also occur, but 
 are exceedingly rare. 
 
 Injuries of the Kidney. — Paipture from falls, kicks, etc., is more 
 frequent than stab or gunshot wounds. The latter are recognized 
 by the course of the missile, bleeding into the bladder, and sometimes 
 
 the discharge of urine from the wound. 
 Subcutaneous injury varies from con- 
 tusion, to fragmentation, or complete 
 disruption (pulpef action; of the kid- 
 ney. There is hematuria, and in most 
 cases a hematoma forms in the flank. 
 Intraperitoneal hemorrhage is rare. 
 There is much local pain and tender- 
 ness, and if bleeding is profuse or long 
 continued even in small amount the 
 usual consequences ensue. 
 
 Treatment. — In cases of gunshot or 
 stab wound the kidney should be 
 exposed and the wound tamponed 
 or closed by sutiu-e. There is little 
 prospect of spontaneous arrest of 
 hemorrhage. In subcutaneous in- 
 juries, on the other hand, bleeding 
 frequently ceases when the patient 
 is kept quiet in bed, with ice locally 
 and morphin internally. Salol or uro- 
 tropin should be given. If bleeding 
 is very profuse, and particularly if the lumbar hematoma continues 
 to increase in size, the kidney should be exposed and the wound 
 tamponed, or, better, closed with mattress sutures of chromic gut, 
 
 Fig. 914.— Rupture of right kidney 
 (anterior ^■iew> . Woman, aged thirty- 
 two years, fell, striking loin on a step. 
 Operation for increasing hematoma 
 four hours after injvuy. Fragment 
 sutured to kidney. Recoven.-. Epis- 
 copal Hospital. 
 
OPERATIONS OS THE KIDXEY 
 
 985 
 
 deeply iiistTted aiid including the fibrous ciij)suk'. Xeplirect(jni\' is to 
 be avoided; even a portion of the kidney completely detached may 
 be sutured in jjlace (Tig. 1)14), and if even only one-tenth of what 
 is saved retains its functional activity, the patient is just so much 
 better oil" than if it had been removed. 
 
 OPERATIONS ON THE KIDNEY. 
 
 Position of the Patient. — In lumbar operations the patient should 
 lie prone, with a sand-bag or other support between the costal margin 
 and pelvis. When the kidney has been exposed the patient may be 
 drawn toward the foot of the table, while the sand-bag is kept immov- 
 able. Thus it compresses the lower thorax, enforces abdominal breath- 
 ing, and the kidney tends to prolapse into the wound (Edcbohls). 
 In the abdominal approach the position is similar to that employed 
 in operations on the bile-ducts, but with the patient turned a little 
 toward the healthy side. 
 
 Incisions. — The usual incision for lumbar operations runs parallel 
 to the last rib, and about an inch below it, from the outer border of the 
 erector spinse mass for four or five inches 
 downward and forward. This incision 
 may be extended forward in the course 
 of the motor nerves of the abdominal 
 wall (Fig. 915). The iliohypogastric 
 and ilioinguinal nerves lie just below 
 this incision between the transversalis 
 fascia and the oblique muscles, and 
 should not be injured. If more room is 
 desired at the upper angle of the wound, 
 the lateral arcuate ligament which binds 
 the twelfth rib to the transverse process 
 of the first lumbar vertebra and the 
 quadratus lumborum, may be cut and 
 the rib thus mobilized. By keeping 
 close to the rib there is not much 
 danger of wounding the pleura. This 
 oblique incision divides, at the spinal 
 end, the latissimus dorsi; at the ab- 
 dominal end, the oblique abdominal 
 muscles at their origin from the lumbar 
 aponeurosis. This aponeurosis itself is 
 divided as far backward as the erector 
 
 spina? mass. Then the transversalis fascia is divided. These struc- 
 tures are shown diagrammatically in Fig. 916. When they have 
 been incised the peri-renal fat, enclosed in the fascia of Gerota, is 
 exposed. In infected cases this fatty capsule may be dense, but usually 
 it is easily displaced by the finger, exposing the kidney covered by its 
 true capsule. 
 
 Fig. 91.5. — Incision for exposure of 
 kidnev bv lumbar route. 
 
986 
 
 SURGERY OF THE BLADDER AND KIDNEYS 
 
 In exposure of the kidney by the abdominal route, the best incision 
 is one parallel to the motor nerves, beginning at the semi-lunar line 
 at the level of the umbilicus and running back toward the flank as 
 far as necessary. 
 
 Fig. 916. — Cross-section of left lumbar region, to show structures concerned in 
 operations on the kidney (diagrammatic). 1. External oblique muscle. 2. Internal 
 oblique and transversalis muscles. 3. Latissimus dorsi. 4. Lumbar aponeurosis. 5. 
 Perirenal fascia. 6. Peritoneum. 7. Ureter. 8. Renal artery. 9. Renal vein. 
 
 Fig. 917. — Nephrotomy: The kidney drawn out on the back and its pedicle com- 
 pressed with the fingers. The splitting of the kidney here shown illustrates the operation- 
 (Watson and Cunningham.) 
 
 Nephrotomy. — After exposure of the kidney by a lumbar incision, 
 as indicated above, proceed to enucleate it from its fatty capsule. 
 
OPERATIONS ON THE KIDNEY 987 
 
 Free both |)()les as well as the anterior and posterior surfaces by blunt 
 dissection with the finji;er, and do not atti^npt to deliver the kidney 
 into the wound until it has been thorouf^hly freed. In infected cases it 
 may be impossible to free the kidney, on account of adhesions; hemor- 
 rhage may then be controlled by clami)ing the pedicle with rubber- 
 covered forceps while the kidney is opened. If the kidney can be 
 delivered, control the i)edicle between the fingers (Fig. 917). Incise it 
 longitudinally a little posterior to the convex border, in the bloodless 
 zone, so as to avoid Brodel's white line which overlies the principal 
 vessels supi)lying the renal cortex. Brewer opens the exposed kidney 
 by Hilton's method (p. 51), so as to avoid hemorrhage. Cullen uses a 
 wire which is passed from one pole of the kidney to the other, and is 
 then made to saw its way out through the convex border. 
 
 If the operation is for the removal of calculi (nephrolithotomy) 
 a large cortical incision is desirable, so as to expose all the calices 
 and the pelvis and allow probing of the ureter. If the operation is 
 done merely for drainage, the opening need not be so large. 
 
 If the stones are known to lie in the kidney pelvis, pyelotomy shoul d 
 be preferred to nephrolithotomy. The pelvis is exposed by turning 
 the kidney forward and clearing off by gentle blunt dissection the fat 
 which covers the posterior surface of the kidney pelvis. The pelvis 
 is then incised a short distance from the kidney. After removal of 
 calculi and probing of the ureter, the fatty tissue overlying the pelvis 
 is sutured back in place, as this tends to prevent leakage. Drainage 
 should be by rubber tissue, not by gauze. 
 
 Nephropexy has been sufficiently described (p. 973). 
 
 Nephrectomy. — The kidney is exposed, and, if possible, is delivered 
 through the wound. The pedicle is attacked from below. Clamp 
 the proximal and ligate the distal portion of the ureter, cut between, 
 and leave the ligature long. Expose the renal arteries and vein by 
 blunt dissection, from the front of the kidney; if not too bulky, ligate 
 the pedicle en masse, or transfix and tie on both sides. Leave the liga- 
 ture long. Then catch the pedicle between the kidney and the ligature 
 in forceps, and cut between the kidney and the forceps, removing the 
 kidney, but leaving the forceps on the pedicle, In case bleeding 
 occurs (it may be profuse) the pedicle can be draw^n into the W'Ound, 
 and another ligature applied. If it is impossible to expose the pedicle 
 satisfactorily, it may be clamped and the kidney cut aw^ay. Never 
 tie the ligature while the clamp is in place, since when the clamp is 
 released and the pedicle retracts the ligature may be forced off. It 
 is permissible to hold the pedicle in a clamp while the ligature is being 
 passed (Fig. 918), but before the ligature is tied the clamp must be 
 released. If this is impossible, the clamp must be left in place for 
 four or five days. 
 
 The kidney being removed and all hemorrhage checked, the liga- 
 ture on the ureter is pulled upon, and the ureter drawn into the w'ound. 
 As much as possible of it should be resected, and the end securely 
 ligated. In septic or tuberculous cases it is weW to inject 10 drops 
 
988 
 
 SURGERY OF THE BLADDER AND KIDNEYS 
 
 of carbolic acid, thus ensuring obliteration of its lumen. In cases of 
 
 nephrectomy for tuberculosis, where pyogenic infection is absent, it 
 
 is best if possible to close the wound without drainage. In all cases 
 of pyogenic infection drainage is essential. 
 
 Fig. 918. — Nephrectomy: Manner of clamping and tying the pedicle of the 
 kidney. (Watson and Cunningham.) 
 
 Closure of the Wound. — In all operations on the kidney, whether 
 drainage is employed or not, the same care in suturing the wound 
 should be taken as in abdominal operations. Hernia is not very 
 infrequent if suturing is carelessly done. 
 
CHAPTER XXVI. 
 VENEREAL DISEASES. 
 
 SYPHILIS. 
 
 TiiK path()lop;y of sypliilis is discussed in Chapter III. 
 
 Contagion. The disease may he iiilicritcd (coii^a-iiital s\])liilis) as 
 well as aeciuired. 'i'lie only i)atli()lo»i{'al dill'erence hetween these two 
 forms of the disease is that in the inherited form there is no primary 
 lesion (chancre), the infecting organism having entered the infant's 
 body through its mother's blood or with the semen of the father.' 
 The lesions of syphilis from which the disease may be contracted are 
 the primary lesion (chancre), and the secondary lesions (especially 
 mucous patches). Tertiary lesions seldom if ever convey the con- 
 tagion. In nearly all cases there is at the point of inoculation a pre- 
 existing abrasion, crack, or fissure in the epithelium of the patient 
 inoculated; inoculation through the intact skin is very rare. 
 
 The occurrence of immediate and mediate contagion was also men- 
 tioned in discussing the pathology of syphilis. In most cases syphilis 
 is acquired by immediate contagion, during sexual intercourse. 
 Hence it is classed as a ^'enereal disease." The sores from which the 
 virus is derived being situated on the genitalia, the sore produced 
 by inoculation likewise develops on the genitals. If the disease is 
 not contracted during coitus, the primary lesion usually is not on the 
 genitalia (though it may be), but on the lip, face, or other exposed 
 portion of the body; and is due to direct contact with contagious 
 sores in another individual (immediate contagion) or to mediate 
 contagion through infected towels, eating and drinking utensils, etc. 
 Such patients being regarded as innocent, the disease in them is some- 
 times termed syphilis insontium. In such cases mediate contagion 
 may conceivably cause inoculation in the genitalia; but the presump- 
 tion is strong that a genital sore has been acquired during the venereal 
 act. Yet it is well to remember that such occurrences are at least 
 possible, and care should be taken not to wound the feelings of others 
 
 ' It has not been found possible to produce a similar form of the disease experi- 
 mentally (using monkeys), since the treponema is destroyed by phagocytosis 
 when injected directly into the blood. According to Levaditi and Roche, however, 
 sj'jihilis without any primary lesion has been produced by injecting the organisms 
 into the testicle where they are able to develop. In these cases the first manifes- 
 tations of the flisease corresponded to secondary syphilis, and in so far resembled 
 the congenital form. 
 
 - Until Ricord, in 1S36, pointed out the clinical dififerences between chancre and 
 gonorrhea, these two affections were not distinguished, both, as well as chancroid, 
 being considered lesions of "the venereal disease" (syphilis). 
 
990 
 
 VENEREAL DISEASES 
 
 Fig. 919. — Multiple chancres (penis and 
 abdomen) , the result of simultaneous inocula- 
 tion. Episcopal Hospital. 
 
 and perhaps cause domestic iinhappiness by expressing an unguarded 
 opinion, whicli, after all, may prove erroneous (J. Ashhurst, Jr.). 
 
 Symptoms and Diagnosis of Chancre. — A chancre develops from 
 three to five weeks after exposure, and occurs first as a reddish-brown 
 papule; but usually when first seen exfoliation of the overlying epithe- 
 lium has occurred. The chancre 
 appears as a superficial erosion, 
 which is common, or as a deep 
 excavated ulcer (Hunterian 
 chancre), which is rare. 
 
 In the male, chancre usually 
 develops on the prepuce, fre- 
 num, or glans penis; less often 
 on the body of the penis, the 
 abdomen, or elsewhere. In the 
 female it occurs on the labia, 
 within the vagina, or on the cer- 
 vix uteri; occasionally around 
 the anus or in the perineum. 
 In men it usually attracts at- 
 tention as soon as it develops, 
 on account of its exposed posi- 
 tion; in women, for the contrary reason, it is generallyo verlooked, 
 and they come under treatment first when secondary lesions develop. 
 
 In almost all cases the chan- 
 cre is solitary; if more than one 
 is present, all have been inocu- 
 lated at the same time, usually 
 from numerous secondary le- 
 sions (Fig. 919). The chancre 
 is not auto-inoculable; a person 
 who has a chancre has de- 
 veloped a constitutional disease 
 which runs a regular course, 
 and he is immune to re-inocu- 
 lation (from his own sores or 
 sores of others) until the dis- 
 ease is absolutely eradicated. 
 In all cases the chancre is 
 indurated, at some time in its 
 development. Sometimes in- 
 duration appears before erosion 
 of the epithelium occiu-s, and 
 usually it persists after the ulcer has cicatrized. The induration 
 of a chancre causes it to feel like a piece of parchment or a split 
 pea in the skin, and often the chancre can be picked up, as it 
 were, without causing it to fold on itself or AATinkle (Fig. 920). _ In 
 cases where induration is less evident, it is best detected by slight 
 
 Fig. 920. — Chancre, duration one day; ex- 
 posure two weeks ago. (Also left vari cocele.) 
 Age twenty-one years. Note induration. Ulcer 
 can be picked up in forceps without folding 
 on itself. Episcopal Hospital. 
 
SYPHILIS 
 
 991 
 
 rigidity of the prepuce as this rolls back from the corona glandis 
 
 (Fig. 1)23). This is not an inllannnatory induration: the outlines of a 
 
 chancre (almost invariably round 
 
 or oval) are sharply defined; and 
 
 there is no redness, heat, swelling, 
 
 or abundant secretion from the 
 
 eroded or ulcerated surface. The 
 
 surface of a chancre on a mucous 
 
 membrane may be moist, and 
 
 covered with a thin pellicle of 
 
 fibrin; but one on an exi)ose(l 
 
 surface usually is covered with a 
 
 dry brownish scab. 
 
 The duration of a chancre is 
 self-limited. It heals spontane- 
 ously in a few weeks or months 
 unless complications arise. It 
 leaves a very characteristic cica- 
 trix, which usually but not always, 
 may be identified years later by 
 its circular, shiny, slightly de- 
 pressed appearance (Figs. 921 
 and 922). 
 
 A mixed chancre is a sore in which both the syphilitic and chancroidal 
 viruses have been inoculated.^ Usually both poisons have been inocu- 
 
 FiG. 921. — Scar from chancre on glans 
 penis, seven months previously. Age 
 twenty-two years. (Note also small 
 punched-out ulcer back of prepuce from a 
 healed chancroid.) Episcopal Hospital. 
 
 Fig. 922. — Scar on body of penis from chancre two years previously. Age 
 twenty-six years. Episcopal Hospital. 
 
 1 Until Bassereau in 18.52 pointed out the clinical differences between chancre 
 and chancroid, they were not distinguished, both being regarded as the initial 
 lesion of syphilis. RoUet in 1866 was the first to explain the essential nature of 
 "mixed chancre." 
 
992 
 
 VENEREAL DISEASES 
 
 lated at the same time, but this is not always the case. A chancre 
 may be inoculated subsequently with chancroidal virus, or vice versa. 
 
 Fig. 923. — "Mixed chaiierc." Multiple chancroids, appeared four weeks ago, four 
 day.s after coitus. Induration present for last week only. Note stiffness of prepuce 
 as it is rolled back from corona glandis. Episcopal Hospital. 
 
 In most cases the early symptoms and history indicate that the lesion 
 is a chancroid; and it may be only when the ulcer fails to heal and 
 induration commences (Figs. 923 and 924), or even not until symptoms 
 
 of secondary syphilis appear, that 
 the true condition is recognized. 
 
 Syphilitic Bubo. — Very soon after 
 the appearance of the chancre, 
 the related lymph nodes (usually 
 the inguinal) become enlarged and 
 indurated. INIany nodes are af- 
 fected {pohjgaiKjUonic), and if the 
 
 \\:i 
 
 Fig. 924. — Mixed chancre. Lesion 
 appeared five weeks ago, four days after 
 coitus. Episcopal Hospital. 
 
 Fig. 925. — Syphilitic Iniboes. Age seven- 
 teen years. Coitus January 1.5, chancre of 
 glans penis developed Feljruary 7. Photo- 
 graphed March 22, 1909. Episcopal Hos- 
 pital. 
 
SYPHILIS 
 
 993 
 
 iiifiuinal refjion is involved, almost invariably the alVection is bilateral. 
 Usually the enlargement is moflerate (Fig. 925), but oecasionally I 
 have seen great lumps the size of oranges develop. The individual 
 nodes do not tend to eoalesce, they remain discrete; their outlines 
 are recognizable on palpation; they are neither especially painful nor 
 very tender; they show no evidences of acute inflammation, and never 
 suppurate. These features serve to distinguish syphilitic from chan- 
 croidal bubo, which is -unilateral, infiainmatori/, wry painful; and in 
 which su}>puratio}i is frequent. 
 
 Fig. 926.— Macular syphiloderni ; duration m\< n days; chancre three months 
 ago. Episcopal Hospital. 
 
 Symptoms and Diagnosis of Secondary Lesions.—As noted in 
 Chapter III, \ari()us prodromal symptoms (fever, malaise, headache, 
 vague "rheumatic" pains) often occur during the period between the 
 development of the chancre and the appearance of secondary lesions. 
 This period lasts, on the average, about six iceeks. At the end of this 
 time, often before the chancre has healed, sometimes after its existence 
 has iaeen almost forgotten, and occasionally as the first recognized 
 63 
 
994 
 
 VENEREAL DISEASES 
 
 symptom of syphilis (the chancre having passed unnoted), there appear 
 skin rashes which, though multiform and various, possess certain 
 characteristics by means of which their syphilitic nature usually 
 may be recognized. About this same time the lymph nodes all over 
 the body become enlarged, especially the posterior cervical and epi- 
 trochlear groups. This lymphatic involvement is very characteristic, 
 and often can be relied on for diagnosis when the skin rashes are 
 too faint or fleeting for recognition. There is also falling of the 
 
 hair (alopecia syphilitica); 
 and sore throat, from de- 
 velopment in the pharynx 
 of lesions which correspond 
 to the skin rashes. Affec- 
 tions of the eye, especially 
 iritis, sometimes occur. 
 
 Fig. 927. — Papular sypliihxUrii], .-caling 
 (syphilitic psoriasis): duration one month; 
 chancre three months ago. Episcopal Hos- 
 pital. 
 
 Fig. 928. — Papulo-squamous 
 syphiloderm ; chancre seven months 
 ago. Episcopal Hospital. 
 
 The occurrence in combination of skin rashes, lymphatic enlarge-^ 
 meni, falling of the hair, and sore throat is almost pathognomonic of 
 secondary svphilis. 
 
 Syphilodermas.— The skin rashes of secondary syphilis require more 
 extended description. They are characterized (1) by the so-called 
 protean nature of the eruption, or the appearance simultaneously, or 
 
svi'inLis 
 
 995 
 
 in quick succession, or more than one variety; (2) by their appearance 
 symnictricalh/, all over the body; (3) by the absence of .subject ire symp- 
 toms, the lesions causing no sensation of itching, burning, etc.; and 
 (4) by the ham-red or coppery color of the lesions, especially as they 
 fade away. Tiiey are distinguished from the skin lesions of tertiary 
 syphilis: (1) by their appearance within a more or less definite interval 
 after the primary lesion; this is not true of tertiary lesions; (2) by 
 their general and symmetrical distribution; tertiary skin lesions are 
 local and asymmetrical; (3) they do not spread centrifugally and 
 hence do not assume the circinate and serpiginous character of 
 tertiary lesions; (4) they tend to disappear spontaneously after 
 lasting a few weeks or months, even without treatment; and their 
 disappearance is markedly hastened by mercurial treatment. 
 
 Macular rashes (er\'thema and roseola) usually are the first to appear 
 (Fig. 92()); they may become apparent only after the patient's body 
 has been exposed to the air. Examination in a good light is necessary. 
 
 Fu 
 
 929. — Mucous patches around the labia and anus of a colored woman. 
 Pennsylvania Hospital. 
 
 Papular rashes also occur early. Papules which are exposed tend 
 to scale, and the lesion may resemble psoriasis (Fig. 927). A papular 
 eruption which occurs late is more deeply situated in the skin, and 
 bears a slight resemblance to tertiary lesions (Fig. 928). Papules 
 which occur in a group on the forehead, just below the hair line, tend 
 to become confluent and are termed the corona Veneris. Papules 
 which occur on mucous membranes, or on skin surfaces which are 
 moist and warm (anus, scrotum, labia, infra-mammary folds) have 
 their epithelial covering destroyed by maceration; they are known as 
 mucous patches, or if confluent, as condylomata lata (Fig. 929).^ They 
 
 1 The condyloma latum, or flat wart, is so-called to distinguish it from the ordinary- 
 venereal wart or condyloma acuminatum (p. 1049). 
 
996 VENEREAL DISEASES 
 
 should be looked for in the situations named, as well as in the buccal 
 mucous meml)rane (cheeks, palate, fauces, tonsils, tongue). 
 
 Pvstular rashes occur later than the macular and papular, usually- 
 several months after the primary lesion. The chief varieties are 
 ecthyma, acne, and impetigo. If deep ulcers are formed, character- 
 istic round, white, shiny cicatrices are left. 
 
 Symptoms and Diagnosis of Tertiary Syphilis. — Usually there is 
 an interval of a few or many years between the disappearance of 
 secondary symptoms and the occurrence of those of the tertiary 
 stage. Occasionally, however, no interval elapses, tertiary symptoms 
 appearing wdiile the skin rashes of the second stage still are present. 
 In many cases no tertiary symptoms ever appear, especially if active 
 treatment has been persisted in throughout the secondary period. 
 
 Tertiary lesions may afl'ect almost any tissue in the body. Those 
 which occur in the skin, mucous membranes, subcutaneous tissues, 
 eye, nervous and vascular systems, muscles and fascia, bones and 
 periosteum, and certain of the solid viscera, are of most importance 
 in surgery. 
 
 The skin lesions of tertiary syphilis are deep and destructive. They 
 appear at no definite interval after the primary lesion, they are localized 
 and not symmetrical in distribution, they tend to spread centrifu- 
 gally and to assume a serpiginous form, they show^ no inclination 
 toward spontaneous cure, and treatment by mercury alone rarely is 
 very effective. Their chief forms are the tubercular (not tuberculous; 
 see p. 77), sqvainous, and rupial. 
 
 Syphilitic tuhercules are at first reddish or coppery papules, which 
 tend to early ulceration; as those in the centre heal, the tubercules 
 at the periphery become ulcerated, producing a serpiginous lesion 
 (Fig. 930) which usually is easily recognized. Syphilitic tubercules 
 occur frequently about the eye and nose; where it is important to 
 distinguish them from lupus, and rodent ulcer. The scar which 
 results from a tubercular ulceration is large and quite characteristic 
 (Fig. 931); it will be noted, in the patient represented in this photo- 
 graph, that although both knees (symmetrical portions of the body) 
 have been affected, the lesion on the left side developed seventeen 
 years after that on the right. 
 
 Squamous lesions often attack the palms and soles, where cracks 
 and fissures are frequent, and may be very painful, 
 
 Riqna may occur in one or many patches, following a bullous 
 eruption (Fig. 932). 
 
 In the mucous membranes syphilitic ulceration may cause great 
 destruction. Gummatous lesions of the tongue have been described in 
 Chapter XIX. The palate, fauces, pharynx, etc., may suffer severely; 
 perforation of the palate is not unusual; ''falling in' of the nose is 
 frequent; and sometimes the soft palate grows fast to the vault of 
 the pharynx, completely shutting off the nasal passages from the 
 oropharynx. Strictures of the esophagus, larynx, trachea, and 
 occasionallv of the intestinal canal occur. 
 
svrjiiLis 
 
 997 
 
 In the subcutaneous tissues the most fr('([iiciit k'sion is tlu' sy])liilitic 
 ^Miimna i l-'ig. '.».!;i i. Its cliiiiciil cliaractiTS liavc hceii (k'scrilu'd in 
 ('liai)t(T III. 
 
 In tlie eye the most frocinrnt lesion is syi)liilitic iritis. 
 
 In the nervous system tho lesions ailect chiolly the brain and spinal 
 cord, or their membranes. Lesions of the peripheral nerves are rare. 
 Any lesion of the central nervous 
 system which occurs in a patient 
 who has had syphilis, even many 
 .years previously (Fig. 934), should 
 be regarded as syphilitic until the 
 contrary can be proved. 
 
 In the arterial system the in- 
 fluence of syphilis in causing aneu- 
 rysm has been pointed out in 
 Chapter X. 
 
 Fig. 930. — Tuberculo-crustaceous lesion, in 
 tertiary stage of syphilis. Duration nine 
 months. Episcopal Hospital. 
 
 Fig. 931. — Left knee, active 
 tubercular ulceration of tertiary 
 syphilis in a woman aged fifty 
 years, twenty years after the pri- 
 mary lesion. Right knee and thigh 
 show cicatrices of similar tubercu- 
 lar lesions which developed seven- 
 teen years previously and were 
 three years in healing. Episcopal 
 Hospital. 
 
 Fig. 932. — Syphilitic rupia. Age twenty-six years; duration five weeks. 
 Chancre one year ago. Episcopal Hospital. 
 
 In the muscles, bursse, tendons, and fascia gummatous tumors are 
 not unusual, limiting function by their bulk, by ulceration, or by 
 
998 
 
 VMEREAL DISEASES 
 
 the cicatrices which are the result of healing. Syphilitic panaris and 
 dactylitis (P'ig. 935) have been described in Chaj)ter XIV. 
 
 Syphilis of the bones has been considered in Chapter XIV. 
 
 Of the solid viscera, the lesions of tertiary syphilis affect particu- 
 larly the liver, where gummas may simulate nodular carcinoma. The 
 diagnosis depends on the history of the case, the recognition of other 
 signs (past or present) of syphilis, and the result of medication. At 
 operation gummas usually may be recognized by central softening, 
 if recent, or by the stellate fibrous cicatrix which results when heal- 
 ing has been uninterrupted. Excision may be desirable if calcification 
 occurs. Syphilis of the spleen is rare and of little surgical interest. 
 Syphilis of the testicle is considered in Chapter XXVIII. 
 
 Fig. 933. — Gumma of neck and of lower 
 eyelid, duration six weeks. Patient aged 
 forty-five years, had gonorrhoea twenty- 
 five years previously, no history of chan- 
 cre. Rapid improvement under mixed 
 treatment. Episcopal Hospital. 
 
 Fig. 934. — Paralysis of leftjjfacial 
 nerve from intracranial lesion, thirty 
 years after chancre. Paralysis of 
 sudden onset ten days ago. Epis- 
 copal Hospital. 
 
 Hereditary Syphilis.— It has already been stated that this differs 
 from the acquired form of the disease chiefly in having no primary 
 lesion. It may be inherited (1) from both parents; (2) from the mother, 
 infected either before conception or during pregnancy; or (3) from the 
 father at the time of conception. As the mother in the latter cu-cum- 
 stances is able to suckle her syphilitic child without acquiring syphilis 
 herself (Colles's law, 1837), it was formerly taught that she had ac- 
 quired immunity from the fetus; but as such a mother reacts positively 
 
SYPHILIS 
 
 999 
 
 to the^Vilss(TIllilllll test (p. 1001 ), it is now tjiii^Mit tliat slie has iic(|nirefl 
 syphilis from her Ictus, and that Iht refractoriness to inoculation is 
 thie to the fact that she already has 1 lie disease, t hou.uii in latent form. 
 Profeta's law (hSO")), to the cllcct 
 that a healthy child of syphilitic 
 parents is unable to contract syphilis, 
 is now also explained by the child 
 having the disease in latent form, 
 since such children give a positive 
 Wassermann reaction. Both Colles's 
 and Profeta's laws are merely an 
 expressit)n of the fact stated at jj. 
 990, that any patient who has de\el- 
 oped syphilis is immune to re-inocu- 
 lation until the disease is absolutely 
 eradicated. 
 
 Pregnancy, in the case of syphilis, 
 usually terminates in abortion, in mis- 
 carriage or in still-birth at term. The 
 more attenuated the infection, the 
 more probable is the birth of a living 
 child at term. The child often shows 
 no evidences of syphilis at birth; but if the disease is truly hereditary 
 and not acquired after birth, lesions corresponding to those of the 
 secondary stage almost invariably appear before the age of two weeks. 
 
 Vie. 935. — Syphilitic dactylitis, in 
 a patient aged forty-one years, twelve 
 years after chancre. Episcopal Hos- 
 pital. 
 
 Fig. 93G. — Hereditary syphilis; aged twelve years. Hutchinson teeth; interstitial 
 keratitis; sabre-blade tibiie. Orthopa'dic Hospital. 
 
1000 
 
 VENEREAL DISEASES 
 
 The earliesi symptoms are bullous skin eruptions (pemphigus), 
 mucous patches, and coryza ("the snuffles"). The baby suffers from 
 
 Fig. 937. — Saddle-nose in hereditary 
 syphilis. Age twenty-four years. Also 
 has genital infantilism and chronic otitis 
 media. Episcopal Hospital. 
 
 Fig. 938. — Hereditary syphilis. Age 
 fourteen years; superficial gummata 
 wrongly diagnosed as tuberculosis and 
 eight operations done during last five 
 years. (Dr. W. Walker's case.) Epis- 
 copal Hospital. 
 
 malnutrition and looks wrinkled and prematurely aged. If the period 
 of infancy is survived, further lesions seldom appear until the age 
 
 of six years or older. The most 
 characteristic of these lesions are 
 i)itcrsiitial krrattlis, ''Hutchinson s 
 teeth'' (Fig. 936) (a peculiar notched 
 and inverted wedged-shaped con- 
 dition of the permanent upper cen- 
 tral incisors, first recognized as 
 syphilitic by Jonathan Hutchin- 
 son, ISGl), rhagades or linear cica- 
 trices at the corners of the mouth, 
 saddle-nose (Fig. 937), dactylitis, and 
 sabre-blade tibia (Fig. 461). Super- 
 ficial gummata may be mistaken 
 for tuberculosis of the cervical 
 lymph nodes. (Figs. 938 and 939) . 
 Syphilis of the joints (p. 503) is 
 common in the hereditary form of 
 the disease. In many cases genital 
 Fig. 939.-Hereditary syphilis, same infantilism may exist even if the 
 patient as Fig. 938, three months after bod^' is large and reasonably well 
 
 a course of anti-syphilitic treatment, i? "^ j 
 Episcopal Hospital. lOrmeQ. 
 
sypiiiLis 1001 
 
 Diagnosis of Syphilis. — This has been based for many years solely 
 on tile clinical findings, and as laboratory aids (particnlarly the coni- 
 plieatcd Wasserniann test, HH)()) often are not available, it is very im- 
 portant for the snr<;eon to be able to reeofjnize and attach due sij^nifi- 
 canee to the multiform symptoms of the disease, especially as these 
 ofteii are de\('lo])ed without apparent rej^ularitN' and are constantly 
 modified l)y previous treatment or extraneous circumstances. Often 
 very little assistance can be obtained from the patients themselves, 
 who may be wilfully deceptive in their answers or who may really 
 have failed to notice symptoms sometimes trivial in themselves and 
 frequently sjjread o\"er a lont: term of years. 
 
 The distinction between chancre and chancroid is of great importance, 
 and usually is possible clinically by attention to the points enumerated 
 at p. 1007; but the existence of mixed chancres must be remembered, 
 and also that both chancre and chancroid may be inoculated simul- 
 taneously but in different parts of the body. Moreover, a person 
 already having syphilis may subsequently acquire a chancroid, and 
 this may be modified by the syphilitic soil in which it is planted. 
 Valuable information may be derived from "confrontation," or the 
 examination of the individual from whom the disease was contracted; 
 but this is seldom possible in this country. 
 
 Extragenital Chancre, particularly on the lips and tongue, must be 
 distinguished from carcinoma. This usually may be done clinically 
 by observing the early palpable enlargement of the neighboring 
 lymph nodes in chancre, and the effect of antisyphilitic treatment. 
 ]\Iicroscopical study of a section of the suspected ulcer is a sure 
 method, but like other laboratory aids is not always available. 
 
 In the diagnosis of secondary and tertiary lesions the surgeon must 
 rely not upon any one or two symptoms, but upon the coexistence of 
 a number, and especially upon their course and order of development. 
 A surgeon meeting with a case of iritis or of cutaneous eruption, or 
 of periosteal "rheumatism," in a person of notoriously lax morality, 
 should not at once jump to the conclusion that the disease is syphilitic; 
 for to do so would be as unphilosophical as it might be unjust. If, 
 on the other hand, a patient should suffer from frequent attacks of 
 recurrent iritis, copper-colored eruptions of various forms, post-cervi- 
 cal engorgement, alopecia, and occasional development of mucous 
 patches; or from osteoscopic pains, indolent nodes and gummatous 
 tumors of the areolar tissue — even though such a patient should appear 
 as virtuous as Joseph or as wise as Penelope — the surgeon might 
 reasonably conclude that he had to deal with a case of syphilis, and 
 should direct his remedies accordingly (J. Ashhurst, Jr.). 
 
 Laboratory Aids to Diagnosis. — In many of the ulcerated lesions of 
 syphilis, especially the chancre and mucous patches, it is possible to 
 find the Treponema pallidum by microscopical study of smears with 
 dark field illumination, or after proper staining. The Wassermann 
 or complement-fixation test for syphUis is now in almost universal 
 use, and is considered perfectly reliable within certain limits. The 
 
1002 VENEREAL DISEASES 
 
 test is of highly technical nature, and requires long practice and vast 
 experience for its proper performance; many of the tests are useless 
 because these exacting conditions are not fulfilled. Then the test 
 sometimes is not positive during the earliest stage of syphilis (chancre), 
 nor as a rule during the secondary stage if the patient has been under 
 active antis^'philitic treatment. It is of greatest value in the third 
 stage of the disease, and in para-syphilitic affections, since here the 
 patient usually has not been under active treatment for a long time, 
 and if the test is positive it may be considered conclusive evidence 
 that the patient is still suffering from syphilis. Even this does not 
 prove, however, that the lesion in question is necessarily s}"philitic. 
 In the case of hereditary syphilis, also, a positive Wassermaun reac- 
 tion may indicate that a chUd of syphilitic parents is itself actively 
 infected, or it may indicate merely that the child has syphilis in a 
 latent form, in accordance with Profeta's law. Whether or not a 
 positive Wassermami test may be obtained in the third or fotu-th 
 generation of patients suffering from latent s\'philis is not certain; 
 but I am inclined to believe that it may. Certainly the fact that the 
 test is positive often is the only evidence, however remote, which can 
 be obtained to indicate that the patient or his ancestors ever were 
 infected with syphilis. 
 
 Treatment of Syphilis.' — As s\-phihs is a general infection, consti- 
 tutional treatment is much more important than local. It has been 
 found by several centuries of experience that the most useful internal 
 remedies are mercury and the iodides. The first of these is antiseptic, 
 and probably acts directly on the parasite which causes the disease, 
 thus being specially indicated during the active stages of s^-philis; 
 while the iodides, which aid elimination, are chiefly beneficial (either 
 alone or combined with mercury) in the tertiary stage. Since the dis- 
 covery of the microbic cause of s\-philis, renewed efforts have been 
 made to secure some drug which shall once and for all destroy the para- 
 sites which cause the disease and thus produce rapid cure. At first 
 it was thought that this Sterilisatio Magna had been provided in the 
 arsenical compound known as Salvarsan, the six hundred and sixth 
 ("606") chemical s^Tithetically prepared by Ehrlich, with this end 
 in view, and fiu-nished to the pubUc in 1909. To this remedy has 
 succeeded, lately, neosaharsan. But it has become evident that while 
 these preparations are of exceedingly great efficacy in certain cases, 
 their use only supplements and does not supplant that of mercm-y 
 and the iodides. 
 
 Tliroughout the continuance of the disease, strict rules of hygiene 
 must be observed. In alcoholics, nephritics, and the tuberculous, 
 the prognosis is bad. In otherwise healthy patients the disease is not 
 only curable, but often rapidly so. The patient must not drink any 
 alcoholic liquors. He mtist not smoke nor chew tobacco, as these 
 habits favor the development of mucous patches. He should have his 
 
 ^ The question of venereal prophylaxia is mentioned at p. 1011. 
 
SYPHILIS 1003 
 
 tcetli i)ut into ,i:;()()(l onk-r, and sluuild keep tliciii in ^ood coiiditioii 
 throiigliout the disease, lie must take <;reat care of his skin, l)athing 
 frequently and paying special attention to regions where mucous 
 patches are apt to develoj). He nuist be careful in liis diet, lie must 
 not kiss any one on the lips; nuist sleep alone; nuist never use a common 
 towel, drinkini;' cu]), or other utensil likely to sj)read contagion. 
 
 Treatment of the First Stage. -Unless the diagnosis of chancre is 
 positive, 1 believe it is improper to administer constitutional treat- 
 ment until the appearance of secondary symptoms renders the exist- 
 ence of syi)hilis certain. The reason for this is that, if the sore is not a 
 chancre, no secondary symptoms will appear under any circumstances, 
 and if the sore is wrongly suspected of being a chancre, and consti- 
 tutional treatment is administered, the subsequent failure of secondary 
 symptoms to ap])ear may be attributed to the treatment employed, 
 and both physician and patient will still entertain the erroneous opinion 
 that syphilis is present. Hence is apparent the extreme importance 
 of reaching an accurate diagnosis in the first stage of the disease, 
 by careful clinical study and laboratory work. 
 
 If in any manner the diagnosis of chancre is incontestable, then the 
 patient should be put upon constitutional treatment at once, since 
 there is very little doubt that this will render the subsequent course 
 of the disease less severe. The best way to administer mercury inter- 
 nally is in the form of the protiodide (hydrargyri iodidum flavum) 
 in doses of from | to j grain (0.008 to 0.016 gram). The tolerance of 
 the patient for this drug must be ascertained, and the dose must 
 be kept just below this point. Usually it is well to combine a tonic, 
 such as iron, with the mercury. Whenever mercury is being taken 
 the patient should be directed to snap his teeth together occasionally, 
 to ascertain the first occurrence of tenderness of the gums; the dose 
 is then reduced slightly. Should salivation, unfortunately, occur, the 
 drug must be stopped at once, and cleansing mouth washes used. 
 
 Locally, little need be done for the chancre, beyond keeping it 
 clean and dusting it occasionally with some inert powder. Cauteriza- 
 tion is not only useless but harmful; and the uselessness of excision 
 with a view of arresting the disease, was pointed out in Chapter HI. 
 If the buboes which attend a chancre are painful, they may be 
 covered with ichthyol or belladonna and mercury ointment, and 
 slight pressure may be applied by a firm bandage. 
 
 Treatment of the Second Stage. — If constitutional treatment has been 
 begun in the first stage, no secondary manifestations may appear; 
 but it will still be necessary to continue treatment since experience 
 has shown that not only may its discontinuance be followed by the 
 appearance of secondary lesions, but that the occurrence of tertiary 
 lesions is more certain and their character more severe, while after 
 prolonged and proper treatment during the second stage they usualh' 
 are mild if they appear at all. A continuation of the internal adminis- 
 tration of mercury is the least distasteful treatment for the patient, 
 and if the protiodide has been given successfully during the first stage 
 
1004 VENEREAL DISEASES 
 
 it may be continut'd iiiti) the second; or wliat is probaMy l)etter, the 
 bichloride or the binicxUde of mercury (hydrargyri iodidum rubrum) 
 may be given in doses of from ^ to g grain (0.004 to 0.008 gram), 
 three times daily in pill form. If a tonic seems indicated, a mixture 
 may be made up with the compound tincture of gentian, the com- 
 potmd syrtip of sarsaparilla, or the tincture of the chloride of iron. 
 
 If the patient first comes under treatment when the second stage is 
 fully developed, there is no better method to gain prompt control of the 
 symptoms than by inunctions of mercury; indeed, I much prefer this 
 method of administration in all cases, but patients often object to it 
 as imcleanly. About a dram of the L'nguentum Hydrargyri is to be 
 rubbed into a non-hairy part of the body once daily. The same part 
 of the body should not be employed again except after an interval 
 of several days: this is accomplished by using in succession the two 
 sides of the thorax, the two flanks, and the epigastrium. The patient 
 should make the inunctions himself; if made by another, gloves should 
 be worn to prevent absorption through the hands. The patient 
 should wear the same underclothing for a week before bathing and 
 removing the excess of mercury. When the symptoms are thoroughly 
 under control Tusually within a few weeks) inunctions may be dis- 
 carded if the patient desires, and mercury may be administered by 
 mouth, as above described. Should active symptoms recur, it is best 
 to resume inunctions temporarily. 
 
 The hypodermic administration of mercury salts has been tried but 
 abandoned by most who were at one time enthusiastic advocates 
 of the method. It has been fotmd painful, dangerous, and unreliable. 
 Intramuscular injections are hotly advocated by E. L. Keyes, Jr.; 
 he prefers a mixture of hydrarg\Ti salicylatis 3 parts, and alboline 
 (or benzinol) 30 parts. From 5 to 10 cgm. are injected once or twice 
 weekly into the gluteus maximus. Mercurial fumigations are used 
 by some, but never have been widely adopted. 
 
 Administration of mercury in some form should be continued at 
 least for two years and a half after the initial lesion. Some follow 
 the intermittent method: give mercury for six months, then stop 
 for a month; then give it for three months, then stop for two months. 
 This includes the first year. During the second year mercury is given 
 for eight months at intervals. Continuous administration is prefer- 
 able; and after cessation at the end of two and a half or three years, 
 the administration of mercury should be resumed if symptoms recur, 
 or if a positive Wassermann reaction develops; and should then be 
 continued at intervals until this reaction remains constantly negative, 
 even after treatment has been stopped for some months. 
 
 Treatment of the Third Stage. — Here the iodides should be taken, 
 usually in combination with mercury, which markedly enhances 
 their effectiveness. Potassium or sodium iodide may be given in 
 doses beginning with 5 or 10 grains, thrice daily, and increased to a 
 point just short of iodism. In deep lesions, especially of bone, immense 
 doses are tolerated. Local treatment of external lesions in this stage 
 
CHANCROID 11)05 
 
 is an iiiiportnnt adjmiint to constitutional treat tncnt, l)Mt without 
 the hitter is ahsohitely inefficient. 
 
 Treatment of Hereditary Syphilis. — If eitlier i)arent is syphilitic 
 the mother shouhl be treated (hiring pregnancy. Tiiis reduces the 
 chance of miscarriage, and favorably influences the course of the dis- 
 ease in tlie chihl Treatment of the mother shouhl be continued 
 throughout lactation for the infant's sake, quite apart from any 
 indication for treatment on her own part. Inunction is the safest 
 and surest method of administering mercury to the baby; a few grains 
 of blue ointment may be spread on the infant's binder, daily, and 
 allowed to work its way into the skin by the baby's movements. For 
 later lesions (bones and joints) iodides also should be given. In most 
 cases tonics are indicated, especially iron and quinine. 
 
 Treatment of Syphilis by Salvarsan. — This is a powerful antiseptic, 
 and ra])idly kills any syphilitic parasites with which it is brought into 
 direct contact. It has no eliminative action like the iodides, and is 
 useless for lesions to w^hich it cannot be conveyed directly through 
 the blood-stream. It is administered by intravenous injection. The 
 usual dose is 0.6 gm., in 40 c.c. of freshly prepared and sterile physiologi- 
 cal salt solution. This mixture is rendered alkaline by adding, drop 
 by drop, 1 c.c. of a 15 per cent, solution of sodium hydrate, constantly 
 agitating the mixture. Then enough salt solution is added to make 
 300 c.c. Thus each 50 c.c. of the entire mixture contains 0.1 gm. of 
 salvarsan. 
 
 Though occasional deaths, and a few cases of blindness and serious 
 lesions of the central nervous system have been recorded as following 
 its use, and presumably caused by it, no hesitation need be entertained 
 in its employment in any case where a rapid amelioration of symptoms 
 is imperative. That it is absolutely curative in some cases is indicated 
 not alone by the sudden and permanent disappearance of all symptoms, 
 but also by the persistently negative Wassermann tests, and in a few 
 instances by the fact that patients have lost their immunity to syphilis 
 and have again acquired the disease. In most cases it is necessary 
 to continue the use of mercury and the iodides after the injection 
 of salvarsan, even if this has been repeated one or more times, as it 
 mav be at intervals of not less than one week. 
 
 CHANCROID. 
 
 The Chancroid, or Ulcus Molle (to distinguish it from the syphilitic 
 chancre or ulcus durum), is now generally believed to be caused by 
 infection with the Bacillus of Ducrey (1889). According to Sovinsky 
 (1904) a pure culture of this bacillus will produce chancroids in man 
 and in animals. The infection is strictly local, and always is acquired 
 by inoculation from a similar sore. Usually it is acquired in coitus, but 
 mediate transmission is possible. The lesion is auto-inoculable; from 
 its first appearance and so long as it remains unhealed, other chancroids 
 
1006 
 
 VENEREAL DISEASES 
 
 may l)e inoculated from the pus which flows over the surrounding 
 skin. 
 
 Chancroid occurs oftenest on the genital organs — especially on the 
 prepuce, corona glandis, frenum, and urinary meatus in the male; 
 and in the female on the labia or os uteri. But any part of the body 
 exposed to the contagion may be inoculated. It is not very rare for 
 inoculation to occur through unbroken skin; but usually some minute 
 abrasion or excoriation is already present. 
 
 Clinical Course and Symptoms. — There is no distinct period of 
 incubation. Usually the next day after exposure the patient feels an 
 itching or tingling at the point of inoculation; a minute papule rapidly 
 forms, and this in another day becomes a vesicle, then a pustule 
 which either ruptures and exposes an ulcer, or becomes scabbed. 
 Thus by the fourth to sixth day the lesion is fully developed. An ulcer 
 which appears later than the tenth day after exposure is not a chan- 
 croid. In about 80 per cent, of cases multiple chancroids are present. 
 These may have been inoculated simultaneously, or may have been 
 inoculated one after the other from the single original lesion. 
 
 A chancroid appears as a rounded or oval ulcer, apparently punched 
 out of the skin, with sharply defined and undermined margins (Fig. 
 924). It varies in size from less than 0.5 cm. to 1.5 cm. in diameter; 
 it is not adherent to the underlying tissues, is surrounded at first by 
 a reddened area of inflammatory reaction, discharges profusely pus 
 which is auto-inoculable, and is covered by an adherent grayish slough. 
 There is a certain amount of inflammatory induration about the base 
 of a chancroid, but it is not sharply limited and does not resemble 
 the parchment-like induration so characteristic of triie chancre. 
 
 Fig. 940. — Left intruinal bubo, one week after development of chancroid on frenum. 
 No bacillus of Duerey found in pus, and bubo healed promptly after incision. Episcopal 
 Hospital. 
 
 Chancroidal Bubo. — In many cases, but not in all, the related lymph 
 nodes become inflamed, and suppuration is very frequent. This 
 complication usually develops within the first two weeks, but occasion- 
 ally not for several weeks after the chancroid has healed. Suppura- 
 
CHANCROID 1007 
 
 tioii in the l)ul)() luuy result from secoiulury infection of tiie cliancroid 
 with pyogenic microbes (the bubo being then similar to the ordinary 
 huhon (Vi'm})lf'C, p. 209), or may de (hic to direct al)sorption through 
 the lymphatics of the Jiacillus of Ducrey. Absorption of toxins 
 produced by this bacillus is not a sufhcient explanation. It is believed, 
 however, that the Bacillus of Ducrey is self-destroyed by the toxins 
 it produces in the })ubo, and this is held to explain the difficulty of 
 obtaining cultures or smears of tiie organism from the abscess. 
 
 A chancroidal bubo almost always is unilateral (Fig. 940), usually 
 on the same side of the body as the chancroid itself. It is distinctly 
 inflammatory in character from the first, and in no way resembles 
 the indolent syphilitic bubo in which many separate lymph nodes are 
 palpable. 
 
 Phagedenic Ulceration occasionally occurs in chancroid, especially 
 in patients who are in poor constitutional condition from alcoholic 
 or venereal excesses, or who are tuberculous. Serpiginous ulceration 
 also is rare; usually it is seen in the case of inguinal buboes which have 
 been opened without due attention to cleanliness, and have become 
 secondarily infected with the discharges from the original chancroid 
 (Fig. 942). 
 
 Other complications are phimosis, para- phimosis, balanoposthitis, 
 coc.risfencc of syphilis or of gonorrhea, etc. 
 
 Diagnosis of Chancroid. — Herpetic eruptions on the genitalia 
 develop almost immediately after coitus, do not form ulcers by the 
 third or fourth day, but disappear spontaneously. They are not 
 auto-inoculable. Yet a chancroid may develop in an herpetic vesicle, 
 and therefore a distinction before the third or fourth day is not always 
 possible. A chancre appears about three weeks after coitus, not within 
 a few days; it is single, unless multiple from the first, whereas chan- 
 croids usually are multiple even if single at first. A chancre is a super- 
 ficial erosion or an ulcer with hard, elevated, sloping edges, not a 
 punched-out ulcer with undermined edges; it presents a peculiar 
 parchment-like induration and is not surrounded by a reddened 
 inflammatory base; it is almost invariably accompanied by double 
 inguinal bubo, which rarely if ever suppurates, while chancroid often 
 has no bubo and if one occurs it Is unilateral and almost always sup- 
 purates; a chancre has an innate tendency to heal but is followed by 
 constitutional symptoms of syphilis, while a chancroid has no innate 
 tendency to heal and is never followed by syphilis unless a mixed 
 chancre (p. 991) is present. One attack of chancroid aftords no pro- 
 tection against subsequent attacks. 
 
 Treatment of Chancroid. — Some mild chancroids may heal under 
 ordinary antiseptic dressings.^ It is possible , however, that such 
 
 1 T. R. Xeilson recommends the following: 
 
 I^ — Hydrargyri chlorid. corros., gr. | 
 
 Zinci sulphat., gr. ix 
 
 Acid, boric, 3 j 
 
 Glycerini, 3 iij 
 
 Aquse, f5 vj 
 
 M. — S. — Apply on absorbent cotton. 
 
1008 
 
 VENEREAL DISEASES 
 
 sores are not true chancroids but only herpetic ulcerations infected 
 by pyogenic cocci. In most chancroids the surest and occasionally 
 the only way to secure healing is to destroy the specific microbes by 
 cauterization. For this purpose I have never found anything so 
 efficient as fuming nitric acid. Some surgeons much prefer carbolic 
 acid, or even the actual cautery. If the chancroid is large, or the 
 patient very timid, it may be necessary to administer an anesthetic. 
 But in the average dispensary case (and it is only in the lowest class 
 of such patients that chancroids are seen — it is a disease of filth) no 
 anesthetic is necessary. Cauterization should not be employed unless 
 the diagnosis is certain; it produces induration and makes difficult 
 a distinction from the initial lesion of syphilis. When it is employed, 
 thoroughness is requisite. The best way to apply nitric acid is by 
 means of a stick about the size of a pencil smoothly rounded off at one 
 end. The surrounding healthy skin should be protected from the acid 
 by smearing it with olive oil or vaselin, and the ulcer is dried. The 
 stick is then dipped in the acid, and is \'igorously rubbed into the 
 ulcerated surface, overlooking no corner or cranny. This destroys 
 the specific microbes, and when the resulting crusts separate it will 
 be found that a healthy granulating surface is left which will soon 
 heal under ordinary antiseptic dressings or ointments. If healing 
 does not proceed normally, cauterization must be repeated, but this 
 is very seldom necessary if it has been properly done in the first 
 place. 
 
 Fig. 941. — Dorsal slit of prepuce to expose chancroids of mucous surface of prepuce. 
 Note inflammatory thickening of prepuce. Episcopal Hospital. 
 
 If the chancroitl is inaccessible on account of phimosis, the foreskin 
 should be slit up the dorsum (Fig. 941), under cocain; then the cut 
 edges and the exposed chancroids are to be cauterized. I have never 
 seen a case where an efficient dorsal slit did not give enough exposure. 
 
 Treatment of Chancroidal Bubo. — It is useless to attempt to treat 
 the bubo until the infecting focus (chancroid) has been cured,. since 
 fresh inoculation will constantly occur through the lymphatics. 
 Prompt treatment of the chancroid itself, as indicated above, fre- 
 
GONORRHEA 1(X)9 
 
 (liK'iitly is siiffick'Ut to cause the hulx) to disappear, even when 
 suppuration aj)pears to threaten. 
 
 I (h) not think it is advisable to open a ehancroichil l)ul)0 until 
 suppuration is very evident; the lonj^er the pus remains in the abscess, 
 the more apt it is to steriHze itself of the chancroidal virus. Yet 
 spontaneous rupture of the abscess is to be avoided at all hazards, 
 especiall\- if the chancroid itself is unhealed; since then the opened 
 bubo will become infected by the discharges from the chancroid, and 
 
 Fig. 942. — Chancroidal ulcer. Age fifty-five \i ;-. Iiuration ten weeks. Bubo 
 developed soon after chancroid of glans, and was allowed to rupture spontaneously; 
 the ulcer then became infected with the chancroidal virus, and showed no tendency to 
 heal. Treated by excision. Episcopal Hospital. 
 
 will be converted into a chancroiflal ulcer (Fig. 942). When the bubo 
 is to be opened, this should be done with careful antiseptic precautions. 
 Where this precaution has been taken, and where the original chancroid 
 was no longer a source of infection, I have never seen any bubo that 
 did not heal promptly under ordinary antiseptic dressings. If the 
 bubo after it is opened becomes converted into a chancroidal ulcer, 
 as indicated above, it must itself be treated as the original chancroid; 
 or the ulcer may be excised and the resulting wound cauterized. 
 
 GONORRHEA. 
 
 Gonorrhea is a local infection of mucous membranes caused by gono- 
 coccus (Xeisser, 1S79; Bumm, 18S7). This is a diplococcus which is a 
 pure parasite, growing best at body temperature and soon perishing 
 when discharged from the body. It is readily killed by heat, and does 
 not survive long in dried secretions. ^Mucous membranes with cylin- 
 drical-celled epithelium are much more easily infected by the gonococ- 
 cus than are those covered with pavement epithelium. The gonococcus 
 is founfl in the purulent exudate, within the leukocytes,^ and invades 
 the submucous tissues easily; it spreads through the lymphatics, 
 
 1 Some pathologists hold that unles.s the diplococci in question are intracellular 
 they cannot be certainly cla.ssed as gonococci; legal proof requires the growth of 
 a pure culture. 
 
1010 VENEREAL DISEASES 
 
 enters the blood stream, and may produce a general infection (a mild 
 form of pyemia). In the latter circumstances secondary localizations 
 in serous membranes are frequent. One such localization, gonococcic 
 arthritis, has been studied in Chapter XVI; gonococcic endocarditis is 
 treated by the physician; and gonococcic iritis by the ophthalmologist. 
 Whether or not gonococcic conjnyictivitis (gonorrheal ophthalmia) 
 ever occurs by infection through the blood-stream is disputed; cer- 
 tainly in most cases infection occurs by mediate contagion through 
 soiled towels, etc. 
 
 Gonococcic Urethritis. — Urethral inflammation due to infection 
 by the gonococcus is the commonest venereal disease. In the female 
 the infection localizes itself especially in the vulvovaginal canal, not 
 so much in the urethra. In man the infection, acquired in sexual 
 intercourse, becomes localized in the anterior urethra, especially the 
 fossa navicularis; unless there is phimosis, causing retention of secre- 
 tions, the glans penis and prepuce usually escape infection owing 
 to the character of their epithelial covering. From the anterior 
 urethra the inflammation usually spreads throughout the entire canal, 
 and is especially apt to remain localized, in chronic form, in the deep 
 urethra and prostate. Throughout the urethra the submucous tissues 
 are invaded, and inflammation of the glands of Littre is common; 
 these may be converted into abscesses, which rupture into the urethra 
 or rarely externally. Inflammation of Cowper's glands is more apt 
 to result in external rupture, and is the chief cause of periurethral 
 abscess fp. 1027) and periurethral urinary fistulse. The healing of 
 these patches of inflammation or follicular abscesses may result in 
 the formation of urethral strictures fp. 1019). 
 
 Symptoms and Clinical Course. — 1. In Acute Gonococcic Urethritis, 
 vulgarly known as the clap, the first symptoms usually appear on the 
 third or fourth day after contagion, and consist in tingling and itching 
 of the urinary meatus. On inspection the lips of the meatus are found 
 swollen, and there is a slight glairy discharge which causes them to 
 adhere between the acts of urination. A scalding sensation in passing 
 water is very frequent. One or two days later a profuse purulent, 
 sometimes blood-stained discharge appears; the ardor urincB lessens; 
 painful erections are frequent; and edema of the foreskin may occur 
 with phimosis or paraphimosis (Fig. 973) and resulting balano-posthitis. 
 Later, fluring erection, the penis may be bent downward or laterally 
 (chordee) ; this painful symptom is due to the inability of the spongy 
 portion of the penis, which surrounds the inflamed urethra, to become 
 elongated to the same extent as the cavernous bodies. Epididymitis 
 (p. 1052) is another frequent complication. In almost all cases of 
 gonorrhea the inflammation extends within a week or ten days to the 
 posterior urethra. This event may pass unnoticed, or may be evi- 
 denced by increasing frequency of micturition, vesical tenesmus, and 
 sometimes by temporary lessening of the discharge. Then as these 
 symptoms abate, the discharge may again increase. Even in severe 
 cases, constitutional symptoms usually are absent. 
 
GONORRHEA 1011 
 
 Acute fionoc'occic urethritis tends to run a self-limited course, almost 
 all symj)t()ms dis;ipj)earin<:; witliiu six to ten weeks, no matter what 
 treatment is employed, or even if no treatment is emj)loyed; hut i)roper 
 treatment usually hastens subsidence of symjjtoms. In almost all 
 cases, however, subsidence of acute symptoms does not indicate that 
 the disease is cured, but merely that it has become chronic or latent. 
 The tronococci remain localized in the deep urethral crypts, in the 
 prostatic utricle, prostate gland, or seminal vesicles, and after any 
 excess in eating or drinking, after excessive coitus, and sometimes from 
 no ascertainable cause, a urethral discharge containing gonococci will 
 appear, may cause a temporary renewal of acute symptoms, and is 
 ca])able of conveying contagion to another individual. 
 
 2. Chronic Gonococcic Urethritis, known also as the gleet, is a very 
 frequent sequel of acute posterior urethritis. The symptoms are 
 insignificant, the most constant being slight mucous or purulent dis- 
 charge (])erha])s only a drop or two) from the meatus, observed w hen 
 the patient wakens in the morning. After defecation, or during sexual 
 excitement, a similar slight discharge may occur. If a sound is passed 
 into the penile urethra, the chronically inflamed urethral glands often 
 may be detected as small nodules, by running the finger along the under 
 surface of the penis. Sometimes vesical tenesmus is annoying at 
 intervals. There may be frequent erections and nocturnal pollutions, 
 and the seminal discharge sometimes is blood-stained. 
 
 Diagnosis. — The diagnosis of acide gonorrhea usually may be made 
 clinically, but it is alwaj's w^ell to stain a smear of the discharge and 
 examine it for gonococci. If the anterior urethra only is involved, 
 and the patient's urine is collected in two glasses, the second portion 
 will be clear, as the urine first passed will have washed away all the 
 secretions. If, however, the posterior urethra is involved, the second 
 glassful of urine will be cloudy or will contain shreds of mucus, since 
 the pressure of accumulated secretions pent up in the deep urethra 
 can force the vesical sphincter and allow the urethral discharge to mix 
 with the urine in the bladder. In chronic gonorrhea it is indispensable 
 to examine the urethral discharge for gonococci. If no secretion is 
 readily available, the prostate and seminal vesicles should be given 
 gentle massage, as indicated at p. 1(313, to force their contents into 
 the urethra. A number of laboratory examinations may be necessary 
 before gonococci can be found. In chronic urethritis the second 
 urine constantly contains shreds. 
 
 Treatment.^ — Certain general directions should be given a patient 
 suffering from gonorrhea. He should be warned of the danger of con- 
 
 ^ The prevention of venereal disease is to be regarded as a scientific and not 
 simply a moral problem. It is self evident that the simplest means of prevention 
 (abstention from impure coitus) is the most efficient, but cannot always be enforced 
 upon patients. In t he case of enhsted men in the army and navy it has been found 
 advisable to adopt definite rules of venereal prophylaxis. Holcomb and Gather 
 (1912) report the results in the United States Navy, where the following rule was 
 enforced after every exposure to venereal disease: (1) Wash the penis (head and 
 shank and under frenum) with 1 to 5000 bichloride of mercury solution, using a 
 
1012 VENEREAL DISEASES 
 
 tagion, especially of gonorrheal ophthalmia ; the possibility of compli- 
 cations, especially epididymitis, should be called to his attention; 
 and he should be instructed as to precautions concerning diet, rest, 
 hygiene, and cleanliness. He should drink plenty of water, and should 
 take no alcoholic liquor at all, unless a confirmed drinker. He should 
 wear a suspensory bandage, and if possible during the acutely inflam- 
 matory stage he should remain in bed with the scrotum elevated. 
 The discharge should not be kept dammed up in the urethra by 
 dressings; but the lips of the meatus should be greased with vaselin 
 and the discharge collected in loosely applied absorbent cotton which 
 is changed frequently. The presence of phimosis may add the com- 
 plication of balano-posthitis, and a dorsal slit of the foreskin may be 
 advisable to secure free drainage, especially if chancroids are thought 
 to coexist. Paraphimosis seldom requires treatment. 
 
 Fig. 943. — Urethral sjringe. (Watson and Cunningham.) 
 
 If the patient is seen in the earliest stages of the disease, before 
 profuse discharge has commenced, it may be possible to secure prompt 
 arrest of the disease by what is called abortive ireatmeni. This consists 
 in the use of antiseptic injections into the urethra, the usual substances 
 employed being protargol (2 to 5 per cent.) or argyrol (5 to 10 per cent.) ; 
 silver nitrate, in strength varying from 1 to 2000 up to 4 per cent., is 
 also used. The patient should urinate before taking the injection, which 
 is administered by means of a glass urethral syringe with blunt nozzle 
 (Fig. 943). This is carefully introduced into the meatus, and the lips 
 of the meatus are closed tightly around the nozzle by the fingers of the 
 left hand, as the piston of the syringe is pushed home with the right. 
 From 2 to 5 c.c. of the solution is injected twice, the second injection 
 being held in the urethra for several minutes. These injections are 
 to be used three or four times daily, except in the case of the very 
 strong silver nitrate solutions, which should be used only once daily 
 and by the surgeon himself, one or two injections often sufficing. 
 In many cases in which this abortive treatment is promptly instituted, 
 the results are excellent; though the urethral discharge may be tem- 
 porarily increased, it soon decreases again, becoming glairy and per- 
 haps blood-stained, and then ceasing entirely, within a week or ten 
 
 cotton sponge. (2) Pass the urine; and take urethral injection of 2 per cent, 
 protargol solution and hold it in the urethra until 60 has been counted. (3) Rub 
 50 per cent, calomel ointment well into foreskin, head, and shank of penis, especially 
 the frenum. They found that: 1385 exposures treated as above in the first .eight 
 hours, gave 19 infections, or 1.37 per cent.; 731 exposures treated as above in eight 
 to twelve hours, gave 25 infections, or 3.4 per cent.; 920 exposures treated as above 
 in twelve to twenty-four hours, gave 46 infections, or 5 per cent. 
 
GONORRHEA 1013 
 
 days. In other cases some discharge persists, and Further treatment, 
 as in the elironie stage, nnist he instituted. 
 
 It' the patient is seen first (hiring the inflammatory stage of gonorrhea, 
 it is not advisahle to use injections, and tiiey should be discontinued 
 if previously empk)yed. In this stage the patient should remain in 
 bed if possible, with tlie scrotum well elevated, especially avoiding 
 sexual excitement. The j)enis should be immersed in hot water 
 several times daily, as the heat not only allays the inflammation but 
 is germicidal to the gonococci. Internally, capsules containing 01. 
 copaiba* nivij, and Oleores cubeb. ITliij may be given, with or without 
 methylene blue (gr. ij) and sandalwood oil (ITlij). Not until the decline 
 of the inflammation should injections be resumed, and as the discharge 
 loses its purulent character and becomes mucoid the stronger anti- 
 septics may be abandoned and astringents given by injection, such 
 as zinc or copper sulphate, lead acetate, etc. The following is the 
 formula of the remedy known as "brue:" I^ — Plumbi acetat. gr. xxx; 
 Zinci sulphat. gr. xvj; Ext. kramerise fl. f5iv; Tinct. opii f'oiij; Aquae 
 destillat. q. s. ad f5 vj. Internally such drugs as salol or urotropin are 
 indicated. As the discharge lessens the strength of the astringent 
 injections should be gradually diminished. 
 
 The treatment of chronic gonococcic urethritis involves discovery, 
 if possible, of the habitat of the remaining germs, and their destruction. 
 For this purpose examination with the endoscope often is advisable. 
 Through this it may be possible to detect superficial ulcerations or 
 erosions of the urethra, the orifices of inflamed urethral glands, etc.; 
 or by the use of bulbed "sounds the presence of a stricture of large 
 calibre (p. 1021) maybe determined; or with the cystoscope the pros- 
 tatic utricle and orifices of the ejaculatory ducts may be investigated. 
 Chronic prostatitis and seminovesiculitis are frequent complications, 
 and it may be impossible to discover gonococci in a chronic urethral 
 discharge until after massage of these structures, as described below. 
 
 For lesions of the anterior urethra, it is best to give irrigations three 
 times weekly. The solution (silver nitrate, 1 to 10,000; potassium 
 permanganate, 1 to 10,000; protargol, 1 to 2000) is allowed to enter the 
 urethra from a fountain syringe, by the force of gravity. After the 
 urethra has been well cleansed in this manner, a soft catheter is passed 
 into the bladder, and this is filled with the solution; the catheter is 
 then withdrawn, and the patient allowed to empty his bladder, thus 
 cleansing the entire lower urinary tract (Horwitz). Strong applica- 
 tions are then made to the erosions through the endoscope. If there 
 is much periurethral infiltration, the passage of large-sized sounds 
 twice weekly is of benefit. Stimulating ointments may be employed 
 by smearing them over the sound and then gently rubbing the corpus 
 spongiosum while the sound is in place. 
 
 If lesions persist in the deep urethra it is well to make instillations 
 of silver nitrate (0.5 per cent.) or protargol (0.25 to 2 per cent.) through 
 a deep urethral syringe (Fig. 944) after massage of the prostate, which 
 is accomplished by introducing the index finger into the rectum, and 
 
1014 VENEREAL DISEASES 
 
 gently stroking the vesicles and each lobe of the prostate downward 
 toward the ejaculatory ducts. Too violent massage may set up a 
 prostatitis or even a proctitis. It is usual to have the patient stand in 
 a stooping posture for massage of the prostate, the surgeon standing 
 behind him; but if the surgeon has a little practice and not too short 
 a finger, it is more convenient to have the patient lying supine. Any 
 urethral discharge which follows massage of the prostate should be 
 examined for gonococci, and if these are found persistently absent 
 
 Fig. 944. — Keyes' deep urethral sjTinge. (Watson and Cunningham.) 
 
 at a number of examinations made at intervals after stopping all 
 treatment, the urethritis may be considered cured. Sometimes pro- 
 longed treatment causes a non-gonococcic urethritis, and cessation of 
 local treatment and attention to the patient's general health may be 
 successful in stopping a discharge which seems otherwise incurable. 
 Microscopical examination of the discharge in such cases may show the 
 presence of staphylococci, streptococci, or colon bacilli. The use of 
 autogenous vaccines may be of use in such cases, as well as in chronic 
 gonococcic urethritis. 
 
CHATTEU XXVII. 
 SUUGERY OF THE URETHRA AND PROSTATE. 
 
 SURGERY OF THE URETHRA. 
 
 Bougies and Sounds (Fig. 945) may be regarded as solid catheters 
 (p. [)i)S). They are used in the diagnosis and treatment of urethral 
 strictures. The bougie (so-called because originally made of wax) is 
 flexible; the old French bougie a houle is inferior to the modern bul- 
 bous-tipped French bougies made of webbing, like English catheters. 
 The best have a core of lead which gives them sufficient weight to 
 facilitate their introduction. Filiform bougies are made of whalebone, 
 and should be perfectly flexible and highly polished. Sounds are 
 metallic instruments; they should be highly polished or nickel-plated, 
 of sufficient weight to sink into the urethra easily, and provided with 
 
 Fig. 945. — Urethral sounds and bougies: 1. Steel sound. 2. Bulbed sound. 3. 
 Bougie a boule. 4. Olive tipped bougie, made of webbing, with a leaden core. 5, 6, 7, 
 Filiform bougies, made of whalebone. 
 
 a suitable handle, to prevent slipping. They are introduced in the 
 same way as metal catheters' (Figs. 946 and 947). Bulbed sounds cor- 
 respond to the bougies a boule; they are of use in determining the 
 extent and site of a stricture, by the sensation they impart to the 
 examiner's hand when the bulb catches on the anterior or posterior 
 face of the stricture. 
 
 Retention of Urine. — Retention of urine is a condition which occurs 
 so often in affections of the urethra, that it is convenient to enumerate 
 its varieties at the outset. First there is (1) Acute Complete Retention: 
 the patient, previously able to evacuate his urine wholly or in part, 
 suddenly becomes unable to do so; all the urine is retained, and the 
 
1016 
 
 SURGERY OF THE URETHRA AND PROSTATE 
 
 Fig. 946. — Passing a sound from the pa- 
 tient's right side. Observe how the sound is 
 held in the fingers, and note that no force can 
 be used. Episcopal Hospital. 
 
 condition is aaite. (2) Acute Incomplete Retention occurs when the 
 patient is just able to void a few drops, with much effort; the condi- 
 tion is acute, but a little of the urine is passed. (3) Chronic Complete 
 Retention, where the patient depends absolutely upon the catheter 
 
 for emptying his })ladder, 
 though the condition is 
 chronic, and the catheter 
 has been required for months 
 or years. (4) Chronic Incom- 
 plete Retention icithoiit disten- 
 iion of the bladder, where a 
 certain portion of urine is 
 constantly retained, but where 
 the major portion is evacuated 
 voluntarily; a chronic condi- 
 tion, where, without the blad- 
 der being over-filled, residual 
 urine exists. Finally there is 
 (a) Chronic Incomplete Reten- 
 tion ^cith distention of the blad- 
 der, where so much of the 
 urine is retained that the bladder has reached the limit of its capacity, 
 and overflow from retention results. 
 
 We may tabulate these conditions as follows: 
 I. Acute Retention. 
 
 1. Acute Complete Re- 
 tention. 
 
 2. Acute Incomplete Re- 
 tention. 
 
 II. Chronic Retention. 
 
 3. Chronic Complete Re- 
 tention. 
 
 4. Chronic Incomplete 
 Retention without dis- 
 tention of the bladder. 
 
 5. Chronic Incomplete 
 Retenfion with disten- 
 tion of the bladder. 
 
 The first of these conditions 
 occurs oftenest as a complica- 
 tion of stricture of the urethra; 
 
 the second in cases of urethritis; the third, fourth, and fifth are seldom 
 seen except in cases of enlargement of the prostate. 
 
 Foreign Bodies. — Foreign bodies may enter the urethra from the 
 bladder (calculi, etc.) or from without. The end of a catheter or 
 filiform bougie occasionally breaks oft'; and sometimes a patient passes 
 implements into the urethra to relieve some fancied obstruction, and 
 the instrument breaks oft' or escapes from his fingers. There is danger 
 
 Fig. 947. — The urethral sound fully intro- 
 duced. Note the angle it makes with the 
 horizon. Episcopal Hospital. 
 
RUPTURE OF THE URETHRA 1017 
 
 of such hodies esciiping into the hladdcr, and they may seriously 
 traumatize the uretiira. It is very important not to introduce a 
 sound incautiously for tlie purposes of diaj^nosis, since it is apt to 
 push the foreign body up into the bladder, or to embed it in the ure- 
 thral wall. It is better to make the diaji^nosis by means of the a'-ray, 
 whenever this is available. It is rare for foreign bodies to produce 
 complete urinary obstruction, but they scarcely ever can be washed 
 out by the stream of urine. Fortunately sufficient time usually is 
 availabkvto send the patient to a well ecpiipped hospital. There it 
 may be possible to extract the foreign body by the aid of the endo- 
 scope, or even l)y alligator forceps (Fig. 94S) introduced closed and 
 opened when they are felt to come into contact with the foreign body. 
 Occasionally a pencil or similar article may be worked out step by 
 step by forcing the penis down over it as it is fixed with the fingers 
 through the perineum or the penile urethra. A hat pin, introduced 
 into the urethra head first may be extracted by protruding its point 
 through the body of the penis, re- 
 versing it, and pushing it out head 
 first. If all other methods fail ex- 
 ternal urethrotomy (p. 1022) should 
 be done; an incision in the penile 
 urethra should be sutured, but one fig. 948.— Urethral forceps. 
 
 in the perineum may be left to 
 
 heal by granulation. If the foreign body has escaped into the blad- 
 der it may be removed by suprapubic cystotomy, if extraction with 
 the operating cj'stoscope is impossible. 
 
 Traumatic Rupture of the Urethra usually is the result of direct 
 injury (falls, kicks, etc.) to the perineum; occasionally it occurs as 
 a complication of fracture of the pelvis. The lesion almost always 
 is in the subpubic urethra, at the bulbo-membranous juncture. The 
 diagnosis depends on the history of traumatism, and the passage of 
 bloody urine or on the symptom of "bloody anuria" (p. 971). In 
 most cases urinary extravasation occurs after twenty-four hours. If 
 the rupture occurs anterior to the superficial layer of the triangular 
 ligament, the urine passes first into the perineum and being confined 
 by Colles's fascia rapidly forces its way through the cellular tissues of 
 the scrotum on to the abdominal walls, through the abdomino-scrotal 
 opening. If rupture occurs above the triangular ligament, the symp- 
 toms resemble those of extraperitoneal rupture of the bladder, but 
 the history of injury to the perineum, with resulting ecchymosis, 
 etc., points to the urethra as the seat of the lesion. If urinary extra- 
 vasation is unrelieved, extensive sloughing will occur, especially if 
 the urine was previously unhealthy ; constitutional symptoms of sepsis 
 are frequent, and death may ensue from this cause. 
 
 Treatment. — Treatment consists first in guarded attempts to enter 
 the bladder with a soft catheter. If this succeeds, as it may very 
 soon after the injury, before urinary extravasation has occurred, 
 the catheter should be left in the bladder for four or fi-\'e days, while 
 
1018 SURGERY OF THE URETHRA AXD PROSTATE 
 
 urinary antiseptics are administered. If extravasation of urine is 
 already present when the patient is seen, the urethra should be opened, 
 immediately, in the perineum, with the aid of a sound passed down 
 to the site of rupture. Numerous incisions in the perineum, scrotum, 
 and skin of the abdominal wall may be necessary to secure free drain- 
 age and avert threatening sepsis. Usually there need be no fear that 
 the patient will be unable to empty the bladder through the wound, 
 and it is not necessary to drain the bladder by a catheter; but if the 
 vesical end of the urethra is readily found this may be done. In a 
 case of rupture of the urethra above the triangular ligament I success- 
 fully employed Demarquay's operation I'lSoSjrthis consists in dis- 
 secting down to the site of rupture through a curved incision con- 
 vexity forward) as in the modem operation of perineal pjrostatectomy 
 (p. 1040). Some surgeons advocate suture of the ruptured urethra ; 
 but in all the cases which have come under my care, the local condi- 
 tion precluded such a step. When the perineal wound begins to 
 granulate, it is usually possible to pass a sound through the penis 
 into the bladder, and if this is done once or t^ice weekly, the perineal 
 wound soon closes. The danger of subsequent stricture formation, 
 however, is very great. Traumatic stricture forms rapidly after injury 
 and the palliative methods and e\ en tlie usual operations employed 
 for stricture the result of gonorrhea seldom prevent recurrence, owing 
 to the dense nature of the scar and its extent. Unless the patient 
 can have bougies passed at least once monthly for many years ('perhaps 
 throughout life,), it is better to excise the strictured area and to unite 
 the healthy urethra above and below by sutures, over a catheter 
 which is left in place for several days or until the urethral wound is 
 healed. I employed this method wdth most happy results in the case 
 of the boy shown in Fig. 953. Though only ten years old, his 
 urethra easily admitted a Xo. IS Fr. sound one year after operation. 
 
 Non-gonococcic Urethritis occasionally occurs, the chief causes 
 being instrumentation, stricture, ingestion of irritating drugs, excessive 
 coitus, or masturbation, etc. If the condition is chronic it probably is 
 kept up by a stricture or a focus of inflammation in the prostatic 
 iu"ethra or its adnexa. The acute form usually subsides so soon as 
 the cause is removed. The treatment of the chronic form is the same 
 as for chronic gonococcic urethritis fp. 1013). 
 
 Prolapse of the Urethra is rare. It occurs oftenest in female 
 children, from straining efforts (coughing, defecation, micturition). 
 The protrusion, which seldom involves more than the mucosa, may 
 be excised, and bleeding checked by pressure, cauterization, or 
 suture. 
 
 Stricture of the Urethra. — Several varieties of urethral -tricture are 
 recognized: 
 
 I. Inorganic Strictures. — 1. Inflammatory Stricture, or obstruction of 
 the urethra from acute inflammation. This is the form which occa- 
 sionally occurs during the acute stage of gonorrhea, resulting in acute 
 complete retention of urine; it also occurs from pressure outside the 
 
STRICTURE OF THE URETHRA 1019 
 
 urethra, from an iiiHamed prostate, periuretliral abscess, etc. It is to 
 be treated by j)alliativc measures sucli as inrlicated under spasmodic 
 stricture, or incision and draina^^e tlir()Uj,di the j)crincum of i)rostatic 
 or periurethral abscesses. IntrcKluction of a catheter shoukl be 
 avoided whenever possible; if retention persists, the bladder may be 
 aspirated above the pubis. (2) Spa.s-niixlic Stricture: This is no 
 stricture at all, merely a si)asm of the urethra, tliough it occurs most 
 often in ])atients with organic stricture. It occurs also as the result 
 of psychic influence (as where an individual cannot urinate in the 
 presence of others), in cases of inflamed hemorrhoids or of semino- 
 vesiculitis, after surgical operations, in the course of the infectious 
 fevers, etc. Spasm usually occurs in the membranous urethra, from 
 the contraction of the deep transversus perinei muscle. // retention 
 is complete, and of eight hours or more duration, a catheter should 
 be used; if incomplete or recent palliative measures may be tried for 
 some hours. Among the most effective is a liot bath, the patient 
 attempting to urinate in the bath; enemas of laudanum, followed by 
 a pmge, may also be used. Recurrence of spasm must be prevented 
 by attending to the condition of the urine, and relieving any local 
 cause, especially organic stricture 
 
 II. Organic Strictures. — (1) Traumatic Stricture has been described 
 at p. 1018. (2j Congenital Stricture is less rare than usually supposed, 
 but may produce no symptoms until the age of puberty or later. 
 (3) Stricture from Cicatrices following Urethritis, almost always the 
 result of gonorrhea, is the type most often seen, and what is said 
 in the following pages refers especially to it. 
 
 Strictures result from submucous round-celled infiltration, which 
 passes through the usual stages of organization, cicatrization, and 
 contraction. As gonococcic urethritis is most frequent al)out the age 
 of twenty years, strictures are seen oftenest in early adult life; they 
 seldom present symptoms for the first time after forty years of age. 
 They may occur in any portion of the urethra, but are most frequent 
 in the subpubic portion, especially the bulbous urethra, but are not 
 rare in the penile urethra. Stricture of the membranous and prostatic 
 uretlu"a is rare. Strictures usually are multiple (Fig. 949), and may be 
 of various forms (Fig. 950). Their calibre varies from that which is 
 impassable to the finest instrument, up to those which barely con- 
 strict the urethral lumen and which may be detected only by the 
 aid of a bulbed sound. The orifice of the stricture may be central 
 or eccentric. 
 
 Symptoms and Clinical Course of Stricture. — ^The early symptoms of 
 stricture usually are insignificant, but occasionally acute retention 
 of urine is the first indication of trouble. In most cases the patient 
 complains first of slight gleety discharge, with pain in the deep urethra 
 during and following urination; he finds the calls to lu-inate more 
 frequent, the stream is diminished in size, and a longer time is required 
 to empty the bladder. Attacks of acute retention are frequent, from 
 inflammatory changes or plugging of the stricture by a pellet of mucus 
 
1020 
 
 SURGERY OF THE URETHRA AXD PROSTATE 
 
 or pus. Retention with overflow is another frequent sequel. From 
 straining in micturition, hemorrhoids or prolapse of the rectum may 
 develop. The urethra immediately behind the stricture becomes 
 dilated, and as backward pressure continues, changes occur in the 
 bladder. The bladder at first may hypertrophy, but in most cases 
 a condition of atrophy (fibroid degen- 
 eration) sets in eventually, so that the 
 bladder loses its power of contraction. 
 This is predisposed to by cystitis, 
 which is prone to develop (owing 
 to stagnation of urine) as the result 
 of instrumentation or as a descend- 
 ing infection from the kidney. Pres- 
 sure diverticida may form in the 
 bladder, and eventually dilatation of 
 the ureters and renal pelves may oc- 
 cur, with hydronephrosis, pyonephro- 
 
 
 V 
 
 Linear 
 Stricture. 
 
 Annular 
 Stricture. 
 
 Fig. 949. — Strictures of the urethra. A 
 probe has been passed through a false passage 
 in the bulbous urethra. (After Albarran.) 
 
 Tortuous 
 Stricture. 
 
 Fig. 950.^ — Diagram of different 
 forms of stricture. (Watson and 
 Cunningham. J 
 
 sis, or surgical kidneys. Other complications and sequels are frequent. 
 The most important 'Pretention of Urine, Urethral Fever. Extravasa- 
 tion of Urine, Periuretlu-al Abscess, Urinary Fi^tuhe,' are discussed 
 in the following pages. 
 
 Diagnosis of Stricture. — While the existence of stricture usually 
 may be surmised fmm it- -yniptoms enumerated above, or from its 
 
TREATMENT OF STRICT U RE OF THE URETHRA 1021 
 
 various s('(|1H'1s, xcrificatinii of tlic diuffiiosis (k'pciids on iiistriiinental 
 cxaniiiiation of tlic urethra. TUv calibre of tlir uornial urctlira corres- 
 pouds with the circuniference of the penis: a circumference of 'A inches 
 implies a urethral calibre of oO mm. of the French scale (p. 959); 
 3 J inches corresponds to 82 Fr.; 85 inches corresponds to 34 Vr., etc. 
 The (tirragc iircflini admits a Xo. '.V2 Fr. sound, but the njeatus usually 
 is smaller than the urethra within. Strictures of large calibre are best 
 detected by passage of a bulbed sound. Such strictures require treat- 
 ment only if productive of definite symptoms. Strictures of medium 
 or small calibre will cause the arrest of an ordinary steel sound of 
 average size. It is always well to commence the examination by 
 passing a full sized sound, and then to try smaller sizes in turn until 
 one is passed into the bladder. It is not safe to use an inflexible 
 sound smaller than Xo. 10 Fr., for fear of making a false passage. 
 
 Treatment of Stricture. — There are two main classes of strictures, 
 the treatment of which it is convenient to consider separately: these 
 are permeable and imyermeahle strictures. By the former is meant 
 a stricture through which an instrument can be passed; and by the 
 latter one through which no instrument of any size or form whatever 
 can be passed. This distinction is relative, since a stricture which a 
 surgeon finds impermeable on one occasion may not be so on another 
 occasion nor for another surgeon. 
 
 1. Treatment of Permeable Stricture. — 1. The best treatment 
 is that by gradual dilatation. A sound just large enough to be grasped 
 by the stricture is passed about twice weekly, and the size of the sounds 
 passed is very gradually increased. Thus if X"o. 14 Fr. has been passed 
 with a little difficulty on the first occasion, it is well to begin the second 
 seance with Xo. 12 Yt., and not to push dilatation beyond X"o. 16 Fr. 
 At the third sitting Nos. 14, 16, and 18 Fr., probably can be passed. 
 It is then desirable in the average case to continue dilatation until 
 a number on the scale is reached which is two or three points higher 
 than that which is considered normal for that patient. But in the 
 case of multiple or fibrous strictures, or in a patient who is old or 
 feeble, or prone to urinary fever or other complication, it is best to 
 be satisfied with keeping a canal patulous for Xo. 22 or 24 Fr. If 
 over-dilatation can be secured gradually, and if it can be maintained 
 for several months, it is probable that no further trouble will be experi- 
 enced. Absorption of the cicatricial tissue will have occurred, and 
 unless a new stricture forms the patient may consider himself cured. 
 In cases where it is impossible to push the dilatation up to normal 
 and beyond, it is necessary for the patient to have a sound passed once 
 monthly for the rest of his life. X'eglect of this precaution wall allow 
 the stricture to recontract, and relief of the patient will then be more 
 difficult. 
 
 2. Treatment by rapid dilatation or rupture of the stricture is, I 
 believe, best adapted to strictures of large calibre, such as sometimes 
 cause persistence of a chronic urethritis; though even in these cases 
 gradual dilatation often is sufficient. Rupture is accomplished by 
 
1022 
 
 SURGERY OF THE URETHRA AXD PROSTATE 
 
 various forms of instruments which are first passed through the 
 strictures and then expanded by some mechanical device (Fig. 951). 
 
 Fir,. 951. — Kollnian's urethral dilator, i Watson and Cunningham.) 
 
 3. Incision of the Stricture (Urethrotomy) is the best treatment for 
 strictures too dense and fibrous to be treated successfully by gradual 
 dilatation; or for those which tend persistently to recur, even after 
 a long course of such treatment. But it should ne\'er be forgotten 
 that it may be more judicious to persist in conservative treatment 
 in the old and feeble, even if it be not curative, than to resort e\en 
 to a trivial operation which may suddenly snuff out life. 
 
 Fig. 952. — 1. Ci\-iale's urethrotome; a model which will cut the stricture from behind 
 forward, or from before backtcard. 2. Sxtne's grooved staff for external perineal urethrot- 
 omy. 3. Tunnelled catheter, threaded over a filiform bougie. 
 
 (a) Internal Urethrotomy (Amussat, 1824) is especially applicable to 
 strictures of the penile lu-ethra: it is accomplished by introducing 
 an instrument through the stricture and then withdrawing from the 
 instrument a concealed blade (Fig. 952, 1), which cuts the stricture 
 on the roof of the canal from behind forward (Civiale's urethrotome, 
 1849), or from before backward (Maisonneuve's urethrotome, 1855). 
 The operation may be done Under local anesthesia (10 per cent, 
 eucain), but a general anesthetic is preferable. After either of these 
 operations it is best to retain an inlying catheter for tliree or four 
 days, the penis being bandaged to it if there is much hemorrhage 
 (which is unusual); and after the catheter is removed, dilatation 
 must be maintained by passage of sounds for several weeks, or longer 
 if a tendency to recontraction is evident. 
 
 (6) External Urethrotomy. — This operation is safer than internal 
 lu-etlirotomy for strictiu-es in the deep urethra. It was popularized 
 by S>Tne in 1843, and is commonly known a? External Perineal Ure- 
 throtomy with a Guide, or Syme's operation: A guide is passed through 
 the stricture from the meatus, and the bulbo-membranous m-ethra is 
 
TREATMENT OF IMPERMEABLE STRICTURE OF URETHRA 1023 
 
 then ()j)eiiecl from tlic i)orincuiii upon the j^iiido heliiiid tiie stricture, 
 and the stricture is divided from behind forward. Syme used a guide 
 jmnidcd witli a f^roove upon its convexity and a shoulder which 
 resteil against the face of the stricture (Fig. 052, 2). After division 
 the stricture should be fully dilated by passage of steel sounds and the 
 bladder drained by a perineal tube for several days, when the passage 
 of sounds may be commenced, and the perineal wound allowed to 
 heal by granulation. 
 
 II. Treatment of Impermeable Stricture. — Very few strictures 
 are really impermeable; indeed, it has been asserted by several eminent 
 authorities that any stricture which would permit urine to escape from 
 above would also admit an instrument from below. But as their 
 experience increased they were forced to acknowledge that they 
 themselves had encountered strictures which remained impermeable 
 to their best efforts. If the patient is able to pass his urine, there 
 is plenty of time available for attempts to render the stricture 
 permeable. Hence it is convenient to discuss the treatment of 
 impermeable stricture according as it is not or is accompanied by 
 retention of urine. 
 
 1. Impermeahh Stridnre uithoni Retention of Urine. — The first 
 efforts of the surgeon should be devoted to rendering the stricture 
 permeable. It is not safe to let a patient with impermeable stricture 
 continue as he is; the risks of retention, urinary extravasation, etc., 
 are too imminent. After trying the usual steel sounds, and finding it 
 impossible to pass the stricture with any, down to No. 10 Fr. (no 
 smaller inflexible instrument is safe) the surgeon should next try fine 
 flexible bougies (those filled with a leaden core are best) which on account 
 of their very flexibility may be enabled to pass through a tortuous 
 stricture which is absolutely impermeable to a rigid instrument.^ If 
 such an instrument cannot be passed (even a No. 1 Fr. may be used 
 without fear of damaging the urethra), //ifor?/i whalebone bougies should 
 be employed. These should be sterilized in the same way as the flexible 
 bougies and catheters, in a cold 5 per cent, formalin solution (p. 
 959). The filiform bougie is passed down to the face of the stricture, 
 where it may be arrested, or may enter a false passage produced by 
 previous instrumentation. In any event it should be left in place, 
 and other filiforms should be passed down beside it, until all the false 
 passages are filled and the face of the stricture is covered by the points 
 of the bougies. Then as the last filiform is introduced it may slide 
 at once through the stricture and into the bladder, the orifice of the 
 stricture being the only point unoccupied.^ Usually not more than 
 six filiforms are introduced at once; by withdrawing each in turn 
 about an inch, and again passing it down against the face of the 
 
 1 As noted at p. 9.59, passage of a bougie usually is easier after distending the 
 urethra with the lubricant by means of a sjTinge. 
 
 - If an endoscope is available, it may be possible to pass a filiform through the 
 stricture under control of direct vision. 
 
1024 SURGERY OF THE URETHRA AND PROSTATE 
 
 stricture with a slight twist, the surgeon seeks to insinuate one of the 
 filiforms into the orifice of the stricture. After working a while on one 
 side of the patient's bed, it sometimes is possible to accomplish more 
 by passing to the other side and commencing all over again, as the 
 surgeon "insensibly works the filiforms toward himself on whichever 
 side he stands (J. H. Brinton). If a filiform finally is passed through 
 the stricture, // should be allowed to remain in place. This applies to 
 any instrument which has been passed through a stricture with great 
 difficulty. The continuous dilatation of the stricture thus produced 
 will render easier the later passage of a larger instrument. When a 
 filiform has been successfully passed through a stricture, all the other 
 filiforms may be withdrawn; and a tunnelled catheter (popularized 
 by Gouley about 1873) may be passed over the filiform into the bladder, 
 and retained in place of the filiform; this acts as rapid dilatation or 
 rupture of the stricture. Some filiforms are provided with a cap and 
 screw thread at their outer ends, so that a larger bougie may be screwed 
 on and pushed through the stricture as the filiform is pushed into the 
 bladder where it curls up. 
 
 In a case a stricture remains impermeable in spite of repeated efforts 
 to pass an instrinnent, resort must be had to operation. As in this 
 operation no guide can be passed through the stricture (as is a pre- 
 requisite for performing Syme's operation), it is known as External 
 Perineal Urethrotomy without a Guide, or Perineal Section,^ Here a 
 sound is passed down to the face of the stricture, and the urethra 
 is opened on this as a guide, in front of the stricture, by an incision 
 through the perineum. The margins of the opened urethra are then 
 caught in guy sutures and pulled taut, while the surgeon endeavors to 
 pass a probe or filiform bougie through the stricture whose face is 
 thus exposed to ^•iew (Arnott, 1822). By forcing a few drops of urine 
 out of the bladder, the orifice of the stricture may become visible. 
 If a probe can be passed through the stricture, the operation is com- 
 pleted as in Syme's method, by dividing the stricture on the guide. 
 But if the stricture cannot be entered, the surgeon proceeds to com- 
 plete the perineal section, dissecting cautiously backward, strictly 
 in the median line, until he has divided the stricture and opened the 
 dilated urethra behind it. This is the part of the operation which 
 gives it the name of perineal section.^ It is an operation which may 
 prove long and difficult, but with a good light and steady hand it is 
 not dangerous. An alternative method is to open the bladder above 
 the pubis, introduce a sound into the vesical orifice of the urethra 
 
 1 External urethrotomy scarcely ever is necessary for strictures of the penile 
 urethra because these very rarely are impermeable; but it may be employed if 
 requisite, the bladder being drained by an inlying catheter, and the incision in the 
 under surface of the penis being allowed to heal by granulation. 
 
 ^ Or the "old operation," the "London operation" (as distinguished from the 
 Edinburgh operation, or Syme's). 
 
 ^ This method, according to Wiseman, was first employed in 1652 by Molins; 
 according to Guthrie it was adopted by Sir Astley Cooper in 1793. The operation 
 was systematized by Jameson, of Baltimore, in 1824. 
 
TREATMENT OF IMPERMEABLE STRICTURE OF URETHRA 102.') 
 
 and make it jirotriulo in tlu> prriiirimi holnnd the stricture; tlie urethra 
 is tluMi opeuetl on this fiuide, throuuii the ])erineuni, and the stricture 
 is cut from behind forward. This method of "retrograde catheteriza- 
 tion," 1 regard as an unnecessary complication; thouj^h it may shorten 
 the operation, it docs not lessen its mortality or imjjrove its results, 
 rather the reverse. It is also possible to open the urethra at the apex 
 of the i)rostate (behind the stricture) by open dissection of the perineum 
 (Guthrie, 1834; Demarquay, 1858) and then to divide the stricture 
 from behind forward ; or to perform Cock's operation (p. ] 026) and com- 
 plete it as did John Hunter (1788) and (luthric (1834) by division 
 of the stricture from behind forward. IJut the best operation in 
 impermeable stricture without retention of urine, is the perineal 
 section, as systematized by Arnott and Jameson. After the stricture 
 has been cut (by whatever method) it should be fully dilated, and the 
 bladder drained for a few days through the perineum. 
 
 Fig. '.1.3.'^. — Acute complete retention of urine from traumatic stricture of urethra. 
 Filiform bougie tied in the urethra. Age nine years, injury six weeks previously. 
 Bladder drained iteslf alongside filiform in forty-eight hours. Treated by excision of 
 stricture. (See p. 1018.) Episcopal Hospital. 
 
 2. Impermeable Stricture with Retention of Urine. — Here there is 
 no time for long delay. There is danger of urinary extravasation, 
 rupture of the bladder, etc., and uremia generally impends from 
 renal complications. Not more than thirty minutes should be spent 
 in attempts to pass an instrument through the stricture; if a filiform 
 can be passed, the bladder will drain itself alongside the bougie within 
 tw^enty-four to forty-eight hours (Fig. 953) and immediate operation 
 is unnecessary. If no instrument can be passed, and if the bladder 
 is much distended, temporary relief may be secured by tapping it 
 suprapubically; and occasionally after the bladder is emptied the 
 stricture becomes permeable. In many cases, however, the bladder 
 is thickened and contracted from cystitis, and is not accessible above 
 the pubis; and even if it is possible to aspirate it in this position, more 
 permanent drainage is required than can be secured in this way. Hence 
 relief of retention is best accomplished by Tapping the Urethra at the 
 65 
 
1026 SURGERY OF THE URETHRA AND PROSTATE 
 
 Apex of the Prostate, known as Cock's operation.^ The surgeon intro- 
 duces his gloved left forefinger into the rectum and places it upon the 
 apex of the prostate. Then he cuts steadily but boldly tlirough the 
 median line of the perineum toward his finger as a guide; when the 
 knife is felt to approach the finger, it is made to cut obliquely, opening 
 the dilated urethra at the apex of the prostate, behind the stricture. 
 The knife is then withdrawn, and a grooved director takes its place, 
 the left forefinger being kept in the rectum to serve as a guide until 
 the director is in the bladder. The finger is then withdrawn from the 
 rectum, and the glove removed. The left hand then holds the grooved 
 director while the right hand passes a catheter along it into the bladder, 
 where it is retained for several days. After this lapse of time the stric- 
 ture usually becomes permeable. The main object of the operation, 
 as I recommend it, is to relieve acute complete urinary retention in cases 
 of impermeable stricture. When the patient has been put out of jeop- 
 ardy by this means, other suitable measures may be adopted to cure 
 the stricture. In many cases it is feasible to follow Hunter's and Guth- 
 rie's advice, and complete the primary operation by division of the 
 stricture from behind forward. In other cases the patient is in such 
 desperate condition when first seen that any prolongation of the 
 operation is injudicious. Cock's operation has often been described 
 as "dramatic in its simplicity," and it is its extreme simplicity and 
 the rapidity with which it may be done that commend it. 
 
 Urethral or Urinary Fever is a form of sepsis due to absorption of 
 bacteria or their products from erosions or abrasions of the urethra. 
 In some patients it is a frequent sequel to the passage of a sound or 
 catheter. Symptoms usually do not appear until after the first act 
 of urination, subsequent to the instrumentation. In most cases there 
 is only a feeling of chilliness, with anorexia or nausea, and some eleva- 
 tion of temperature; but there may be a frank chill. In rare cases true 
 pyemic symptoms develop, with acute monarticular or polyarticular 
 effusion. 
 
 Treatment. — Treatment consists in the internal use of urinary anti- 
 septics for some time before urethral instrumentation, and the admin- 
 istration of a full dose of quinine and opium as soon as the instrumen- 
 tation is completed. In case of severe and recurrent attacks, it may 
 be desirable to drain the bladder by the perineum, until the urethra 
 becomes healtliier. 
 
 Extravasation of Urine has been referred to (p. 1017) as a complica- 
 tion of rupture of the urethra, and its clinical features were pointed 
 out in that place. It occurs not infrequently, also, in cases of urethral 
 stricture, either spontaneously, or as the result of false passages made 
 by careless instrumentation. That false passages are not more often 
 
 ^ This is a variety of the old bouttonniere operation, revived in 1856 by Mr. 
 Cock, of Guy's Hospital, as a treatment for impermeable stricture complicated by 
 urinary fistula', and popularized by him in 1866; he found that when the urine was 
 diverted from the strictured urethra through the perineum, the fistulse tended to 
 heal spontaneously, and the strictiu-e usually became permeable. 
 
URINARY FISTULA 
 
 1027 
 
 accompiiiiiod l)v urinary extravasation is no doubt attributable to the 
 fact that the false passages have their orifices directed away from the 
 bladder. Extravasation of urine occurs sometimes in cases where no 
 stricture exists. One of the worst cases I ever saw was in an old man 
 of seventy-three years, in whom no urethral obstruction existed, 
 and in whom no instruments had been passed. In such cases it is 
 probable that perforation of the urethra occurs as the result of unrec- 
 ognized ulceration or the rupture of a peri-urethral abscess. Treat- 
 ment, as already advised, consists in perineal urethrotomy, and free 
 incisions wherever required to drain the extravasated urine or remove 
 sloughs. 
 
 Peri-urethral Abscess. — Peri-urethral abscess was mentioned at p. 
 1010 as a complication of gonococcic urethritis. Usually one or both 
 Cowper's glands are involved, and a tender swelling appears to one 
 side or other or the median raj)he 
 of the scrotum at its junction with 
 the perineum (Fig. 954). The 
 condition is distinguished from 
 perianal or ischio-rectal abscess 
 by its less acute symptoms, the 
 history of urethral disease, and 
 the location of the swelling in 
 the perineum rather than close 
 to the anus. 
 
 Treatment. — Treatment consists 
 in incising the abscess as soon as 
 it is recognized, in the endeavor 
 to prevent its rupture into the 
 urethra, as this latter result 
 almost invariably entails the sub- 
 sequent formation of a urinary 
 fistula in the perineum. 
 
 Urinary Fistulae. — Urinary fistulse usually are the remote result of 
 gonococcic urethritis, or of neglected cases of extravasation of urine. 
 Usually the fistula? occur in the perineum, but they may be located 
 in the scrotum, in the penis (floor of the urethra), in the adductor 
 region of the thighs, or in the buttocks. In almost all cases the com- 
 munication with the urethra is on the vesical side of a stricture, and 
 proper treatment of the stricture often allows the fistulae to close. 
 In cases where no stricture exists, however, and especially where the 
 fistula is indurated and lined with mucous membrane, it is necessary 
 to do a formal operation. The use of an inlying catheter, and cauteriza- 
 tion of the fistulous orifices seldom is efficient. The urethra should 
 be drained behind the internal orifices of the fistulae by Cock's or by 
 Syme's technique, according as there is or is not an impermeable 
 stricture; a stricture if present should be cut; and the fistulous tracts 
 should be excised, and if possible closed by suture. Perineal drainage 
 of the bladder may be dipensed with after a week and full sized sounds 
 should be passed regularly until the fistulae have healed. 
 
 Fig. 954. — Peri-urethral abscess, on the 
 patient's right. Episfopal Hospital; 
 
1()2S SURGERY OF THE URETHRA AND PROSTATE 
 
 SURGERY OF THE PROSTATE. 
 
 Acute Prostatitis and Abscess of the Prostate. — Usually this is a 
 complication of posterior urethritis (gonococcic), in^'ol^•ement occur- 
 ring by direct extension. In rare cases acute prostatitis may result 
 from the trauma of frequent or careless instrumentation; and occa- 
 sionally prostatic abscess occurs as a metastatic infection in the 
 course of the exanthemas, typhoid fever, pneumonia, etc. 
 
 Symptoms. — The symptoms are both general and local. General 
 symptoms (high fever, typhoid state, muttering delirium) if severe, 
 may completely mask the local condition, which causes intense 
 burning pain in the rectum, with rectal tenesmus and usually reten- 
 tion of urine. Examination hy a finger in the rectinn (extremely 
 painful) detects the enlarged tender prostate. One or both lobes may 
 be involved. Only if an abscess is very near the surface can a soft 
 area or fluctuation be detected by rectal palpation. 
 
 Treatment. — Treatment should be palliative at first. A brisk 
 purge should be given, and the urine rendered alkaline (Watson). 
 Some relief may be secured from hot rectal irrigations and sitz baths. 
 Urinary antiseptics should be administered, and if there is urinary 
 retention it is better to allow a soft catheter to remain constantly 
 in the bladder than to pass it frec|uently. Operation should be done 
 after twenty-four or forty-eight hours unless relief is ol)tained sooner; 
 but if suppuration is suspected operation should be immediate. Only 
 if the abscess is manifestly pointing in the rectum should it be opened 
 by this route; in such cases a drainage tube should be passed within 
 the sphincter ani, but need not enter the prostate. Whenever possible 
 it is better to expose the prostate as in perineal prostatectomy, incis- 
 ing one or both lobes and draining the retroprostatic space by tube or 
 gauze. Even if pus is not found, relief is prompt and lasting. During 
 convalescence it is well to resort to regular prostatic massage. 
 
 Chronic Prostatitis — Chronic ])rostatitis is a still more frequent 
 complication of posterior urethritis than is the acute form of the dis- 
 ease. Usually it is gonococcic in origin, but as a rule secondary infec- 
 tion has occurred, and only the pyogenic cocci or the colon bacillus 
 can be found. It is insidious in onset, and patients may not come 
 under treatment until many years after the causative urethritis has 
 ceased to cause annoj'ance. 
 
 Symptoms. — The main local symptom is a chronic, gleety, urethral 
 discharge. General neurasthenic symptoms are frequent, and referred 
 pain may be felt in the back, thighs, buttocks, groins, etc. The diag- 
 nosis is confirmed by examination of the rather abundant secretion 
 obtained by massage of the prostate (p. 1013). Soon after the primary 
 lesion gonococci or other bacteria are found; but at later periods the 
 secretion is composed almost entirely of pus cells, and even these 
 may not be found until after massage has been employed for the third 
 or fourth time. 
 
ENLARGEMENT OF THK PROSTATE 
 
 1020 
 
 Treatment. The \)vsX trcatinciit is rcjiular prostatic luassuj^e, 
 ahout three times \veekl\ , followed hy urethral and vesical irrigations, 
 and occasionally hy instillation of ."> per cent, silxcr nitrate or the 
 aj)plication of stinuilatini,^ ointments to the deej) urethra. The use 
 of the kollman urethral dilator ( l'\u. !>.")l. ]). 101*2) may also prox'c of 
 \aluc. 
 
 Enlargement of the Prostate This often is spoken of as hypertrophy 
 of the i)rostate, hut in a ])atholo<;ical sense there is no true hyper- 
 trophy, and 1 prefer to retain the term enlargement simplx' because 
 the actual patholouical ])rocess at work in these cases is still in dispute, 
 
 Fig. 9.5.5. — Diagram of a sagittal sec- 
 tion througli the prostatic urethra: 1. 
 Sphincter of bladder (internal) , posterior 
 segment. 2. Pre-spermatic portion of 
 prostate. 3. Ejaculatory ducts. 4. 
 Retro-spermatic portion of prostate. 5. 
 Urethra. 6. Vesical orifice of urethra. 
 7. Internal sphincter of bladder, anterior 
 segment. 8. Suburethral or paraureth- 
 ral glands (group of verumontanum). 9. 
 External sphincter of the bladder. (After 
 Cuneo.) 
 
 Fig. 956. ^Diagram of a sagittal section 
 of the prostatic urethra, in a case of "en- 
 largement of the prostate:" 1. Enlarge- 
 ment (adenoma) of the suburethral glands 
 (Fig. 955, 8). 2. Internal sphincter of 
 the bladder, posterior segment. 3. Retro- 
 spermatic portion of the prostate. 4. 
 Ejaculatory ducts. 5. Pre-spermatic ijor- 
 tion of prostate. 6. Lateral lobes of 
 tumor (adenoma of suburethral glands). 
 7 External sphincter of bladder. 8. In- 
 ternal sphincter of bladder, anterior 
 segment. 9. Neck of bladder. 10. 
 Bladder. (After Cuneo.) 
 
 and because it is the mechanical effect of the enlargement of the 
 gland (urinary ohsirudion) which makes the condition important 
 surgically. The modern hypothesis, put forward by ^Nlotz and Per- 
 earnau in 1905, and supported by researches of E. ]\Iarquis (1910) 
 and Cuneo (1913), is to the effect that so-called enlargement of the 
 prostate is not an affection of the prostate at all, but of the suburethral 
 glands, lying beneath the urethra immediately on the vesical side of 
 the ejaculatory ducts {Y\g. 955). According to this theory, the change 
 is truly neoplastic (adenomyoma), and the tumor displaces and con- 
 denses the prostate beneath and around it as a sort of capsule (Figs. 
 95() and 957). Though this is in accord with the facts that in 
 
1030 
 
 SURGERY OF THE URETHRA AND PROSTATE 
 
 Fig. 957. — Diagram showing in transverse 
 section the relation of the periurethral 
 adenoma to the prostate: 1. Capsule of the 
 prostate. 2. Urethra. 3. Prostate, com- 
 pressed and pushed aside by the new growth. 
 4. Ejaculatory ducts. 5. Adenomyoma 
 (After Cuneo.) 
 
 "enlargement of the prostate" the ejaculatory ducts are depressed far 
 toward the rectal aspect of the tumor, and that the lengthening of 
 the urethra occurs solely in tiint jxjrtion between the verumontanum 
 and the bladder (there is no lengthening of the segment of the pros- 
 tatic urethra on the distal side of the verumontanum), nevertheless 
 this theory has not yet gained very wide acceptance. 
 
 Clinically there are tw^o seemingly distinct forms of enlargement 
 of the prostate: in one the change in the prostate appears to be adeno- 
 matous in character, and the 
 prostate becomes large, soft, or 
 of only moderate hardness; 
 while in the other a sclerosis 
 exists, as if caused by a chronic 
 inflammatory process, and the 
 prostate does not become very 
 large. I believe there is no 
 good evidence that this fibrous 
 type of enlargement is a later 
 stage of the adenomatous form, 
 though this is the teaching of 
 Moullin and some other author- 
 ities on the subject. I believe 
 it is much more probable 
 that the adenomatous form of 
 enlargement is an "adenomatosis" of the prostate (or rather of the 
 suburethral glands), or even a true adenomyoma; while the small 
 sclerotic prostate is the result of chronic injection, and should be classed 
 entirely apart. Ciechanow\ski (1900) and others since his time have 
 sought to show that all cases of enlargement of the prostate were 
 originally inflammatory in origin, the main causative factor being 
 the gonococcus. 
 
 A prostate which is the seat of the adenomatous type of enlarge- 
 ment usually presents on section numerous "prostatic tumors" which 
 compress the surrounding stroma into a capsular envelope, and which 
 grow in the direction of least resistance (toward the bladder) ; here they 
 often project beneath the mucous membrane posterior to the urethral 
 orifice, and are termed (wrongly) "median lobe" enlargements. In 
 some cases the enlarged prostate presents no such distinct tumor 
 masses in its interior, but exhibits general glandular or fibrous 
 enlargement, or a combination of the two forms. The small, hard, 
 sclerotic prostate usually is densely adherent to surrounding struc- 
 tures, and these evidences of former peri-prostatitis lend support to the 
 view that such prostates have been altered by chronic inflammatory 
 changes. 
 
 Any prostate weighing more than six drams (23 grams) may be 
 considered abnormal. From this size they range up to 12 ounces or 
 more. The average weight of prostates removed at operation is about 
 3 ounces. Enlargement occurs chiefly in an anteroposterior direction, 
 
ENLARGEMENT OF THE I'ROSTATE 1031 
 
 and, as the ajK'x of the i)r()stato is fixed against the triangular 
 ligament, growtii oecurs ehiefly toward the vesieal eavity. The two 
 lateral lobes usually are not equally enlarged, and this aeeounts for a 
 rather constant de\'iati()n of the urethra to one or other side. The 
 two lateral lohes may project into the bladder in such a form that 
 the urethral orifice resembles the os uteri; or as already mentioned, 
 a "prostatic tumor" may force its way through the capsule of the 
 prostate and project beneath the vesical nnicous membrane as a 
 nipi)le-like obstruction or as a pedunculated out-growth behind the 
 vesical orifice of the urethra. 
 
 Clinical Pathology. — As the prostate gland enlarges, various changes 
 are j)roduced in the urethra, bladder and rectum; and less directly 
 in the urine, kidneys, and general health. 
 
 Changes in the Urethra. — The length of the normal urethra averages 
 8 inches; but in enlargement of the prostate the length rnay he 14 or 16 
 inches, the increase occurring in the prostatic portion of the canal, 
 especially in that portion on the vesical side of the ejaculatory ducts. 
 This fact also explains the elevation of the vesical orifice of the urethra 
 and the increased curve of the prostatic urethra, necessitating a special 
 curve to inflexible instruments (Fig. 958, 3 and 4). Lateral deviation 
 of the urethra has been mentioned above. In some cases a peduncu- 
 lated enlargement at the vesical orifice produces a Y-shaped channel. 
 Increase in length of the posterior w^all of the prostatic urethra may 
 increase its antero-posterior diameter and consequently its capacit}', 
 so that it may hold an ounce or two of urine; this is rare, but should 
 be remembered as a possibility, since evacuation of a small amount 
 of urine from the dilated prostatic urethra may lead the inexperienced 
 to think the catheter has entered the bladder. 
 
 The most important change in the bladder is the formation of a 
 post-prostatic pouch, due to combined elevation of the urethral orifice 
 and descent of the vesical floor. The greater the obstruction to the 
 outflow^ of urine the larger this pouch becomes, and the more residual 
 urine collects in it. Residual urine is that which remains in the bladder 
 after the patient has expelled all he can. At first some hypertrophy 
 of the vesical walls may occur, but if obstruction is unrelieved dilata- 
 tion and atrophy ensue, and the quantity of residual urine gradually 
 increases. This state of chronic incomplete retention of urine without 
 distention of the bladder (stage of residual urine) is finally succeeded 
 by the same condition with distention of the bladder, and when the 
 limit of the bladder's capacity has been reached, overflow occurs 
 (retention with overflow). The distinction betw'een the latter condition 
 and true incontinence of urine has been explained at p. 599. But 
 cystitis may occur, and then the bladder does not dilate; its walls 
 become thickened and its capacity diminished. Vesical irritability 
 demands frequent evacuation, and retention with overflow is rare. 
 The adenomatous type of enlargement usually is associated with a 
 dilated bladder; while where cystitis and contraction of the bladder 
 are present the prostate usually is small and fibrous. 
 
1032 SURGERY OF THE URETHRA AXD PROSTATE 
 
 The effects on the kidneys and ureters are those usual in other cases 
 of urhiary obstruction, with or without infection (p. 975). 
 
 The residual urine almost invariablj^ become alkaline, and invites 
 the occurrence of cystitis, but if acute retention does not occur, 
 and catheterization is avoided, the occurrence of cystitis may be long 
 postponed. Phosphatic calculi frequently form, but as they are more 
 or less fixed in the retroprostatic pouch may cause no characteristic 
 symptoms. 
 
 Effects on Urination. — Residual urine diminishes the capacity 
 of the bladder; hence urination must be more frequent. Frequent 
 urination increases the existing congestion; this in turn may bring 
 on retention of urine; catheterization is resorted to, once or oftener, 
 and cystitis is the usual consequence. The retention and the infection 
 produce nephritis, the quantity of urine is increased, and this causes 
 still more frequent calls to evacuate the bladder. In this way a vicious 
 circle is produced, and unless the original cause of all this woe, uri- 
 nary obstruction, is removed, the patient's general health quickly 
 deteriorates. Dilatation of the bladder and changes in its walls cause 
 feeble power of expulsion, and slowness in completing the urinary 
 act; while the inability of the vesical neck to act properly and the 
 interference with the action of muscles around the membranous urethra 
 cause the last portions of urine to be voided in dribbles, no power 
 remaining of evacuating it in spurts. 
 
 Effects on the Rectum. — The rectum may be obstructed by an 
 enlarged prostate, causing increasing difficulty in defecation; and the 
 constant straining in micturition is a frequent cause of hemorrhoids 
 and pr(.)lap-^us. 
 
 Symptoms and Clinical Course. — Symptoms seldom are observed 
 before the age of fifty years, but usually enlargement is present for 
 some time before notable symptoms are produced. Usually the 
 disease is insidious in onset, and the first abnormality noted is noc- 
 turnal frequency of urination. Urination probably is as frequent by 
 day, but does not arrest attention. Sometimes involuntary dribbling 
 of urine is the first sign of trouble, usually due to retention with over- 
 flow. Occasionally acute retention is the first symptom. Starting 
 the stream is difficult, because there is both increased obstruction to be 
 overcome, and decreased expulsive power; the stream tends to drop 
 vertically from the meatus; a longer time than usual is required to pass 
 the urine, though the amount evacuated each time may be small; 
 and the urine dribbles at the end of the act of urination. Retortion of 
 urine is noticed by the patient only when acute, or when the chronic 
 form is accompanied by overflow. The symptoms of cystitis and renal 
 complications need not be detailed here. Hematuria seldom occurs 
 spontaneously, but may follow the most gentle catheterization, from 
 rupture of varicose urethral or vesical veins. 
 
 Patients with enlarged prostates may be divided roughly into three 
 classes (Deaver and Ashhurst, 1905): in the earliest stage the chief 
 complaint is nocturnal frequency of urination; in the second stage 
 
ENLARGEMENT OF THE PROSTATE 103/1 
 
 patients suffer ocoasionall,\ from complete retention, hut ;ire not inucli 
 trouhled by cystitis and enjoy fairly <;oo(l health; while in flir third 
 sfiuir urinary retention is nearly absolute, the bladder cannot be e\ac- 
 iiated without a catheter, the kidneys are markedly diseased, and the 
 patients are on the xerj^e of the f:;rave. 
 
 Diagnosis. — 1 )iagnosis of enlargement of the prostate cannot be 
 made from the symptoms alone; physical examination is retjuired. 
 The first and most important sign to be looked for is a distenrled 
 bladder; neglect to observe this sign, and the hasty and injudicious 
 introduction of a catheter in cases of long standing retention with 
 o\erHow may cause immediate syncope (from decrease of intra- 
 abdominal pressure), and may lead in a few days to the patient's 
 death from renal congestion and uremia. The proper treatment of 
 retention with o^•erflow is given at p. 1035. Having noted the absence 
 of a distended bladder, request the patient to pass all the urine he 
 can, and note the facility with which he starts the stream, the force 
 with which it is expelled, and the presence or absence of dribbling 
 at the end of urination. The amount of urine passed should be meas- 
 ured, and the habitual frequency of urination noted. A patient who 
 passes four ounces of urine, more or less, every two hours, probably 
 has no serious renal lesion. If he passes four ounces only every three 
 or four hours, either the normal amount is not excreted by the kidneys 
 or the quantity of residual urine is rapidly increasing. If on the other 
 hand half an ounce or an ounce is passed every ten or fifteen minutes, 
 the kidneys will be excreting from 50 to 150 ounces of urine daily, 
 and retention with overflow probably exists. If the bladder is not 
 distended, the surgeon should next insert a catheter, to ascertain the 
 quantity of residual urine. For diagnostic purposes (not for treat- 
 ment by catheterism, p. 1034) I prefer a metallic instrument, since it 
 acts also as an exploratory sound. As this is passed, note the presence 
 or absence of strictures, any deviation of the subpubic urethra, the 
 height to which the vesical orifice is raised, and the distance from the 
 external urinary meatus at which urine begins to flow\ ThefoUmving 
 facts favor the diagnosis of enlarged prostate: if the shaft has to be 
 depressed unduly between the patient's thighs before urine flows, 
 indicating elevation of the vesical orifice of the urethra; if the urinary 
 distance (that from the meatus to the point at which urine commences 
 to flow) is increased above 8 inches; if the catheter deviates laterally 
 in the prostatic urethra; or if the catheter meets an obstruction more 
 than 7 inches from the meatus, showing the obstruction is further 
 back than the usual site of strictures. A small amount of urine 
 evacuated from the dilated prostatic urethra should not deceive the 
 examiner into thinking the bladder has been reached. 
 
 The amount and character if the residual urine are now noted; and 
 finally a few ounces of saline solution are injected into the bladder, 
 and the metal catheter is used very gently as a sound to explore the 
 condition of the vesical walls and to search for calculi in the post- 
 prostatic pouch. Before the catheter is removed, insert a finger into 
 
1034 SURGERY OF THE URETHRA AND PROSTATE 
 
 the rectum and palpate the prostate; the intravesical instrument 
 can then be regarded as a very long finger, and the prostate can be 
 palpated between this and the finger in the rectum. 
 
 Treatment. — This may be discussed under the headings: (1) General 
 treatment; (2) palliati\'e treatment, which includes catheterism and 
 certain palliative operations; and (3) radical treatment by prosta- 
 tectoni}'. 
 
 1 . General Treatment is important. Especial attention should be 
 paid to diet, to hygiene, and to securing free evacuation of the bowels. 
 Cascara or some similar laxative is to be preferred. Atropin never 
 should be given long at a time, for fear of increasing vesical atony; 
 hence the popular A. B. & S. pills should be avoided. Drugs are not 
 of much value for the prostatic condition, but during an accession of 
 prostatic and vesical congestion the use of a prescription such as that 
 advised at p. 907, for a "fit of the piles," often procures marked relief. 
 The urine should be kept acid, by administration of benzoic acid 
 in 5 grain doses, with twice the quantity of sodium borate to ensure 
 solution; and if the urine is not too acid urotropin is the best anti- 
 septic. For excessively acid urine it is best to increase the ingested 
 fluid, to decrease the sugars, and to administer alkaline salts of 
 potassium or sodium. 
 
 2. Palliative Treatment. — Catheterism consists in periodical evac- 
 uation of the residual urine by use of a catheter. This will cure no 
 patients, but may promote their comfort, and in the very aged or 
 feeble may even prolong life. As the expectation of life, however, 
 in patients treated by catheterism is in the average no more than four 
 or five years, it is clear that the life of the average patient is shortened 
 by such treatment. I do not recommend it except when prostatectomy 
 is contraindicated. The frequency of catheterization depends entirely 
 upon the distress occasioned by residual urine, yromded the latter is not 
 increasing in quantity. As a general rule a patient with 4 ounces of 
 residual urine requires to be catheterized once in twenty -four hours; 
 the best time is just before going to bed. If 6 ounces are present, use 
 the catheter twice, night and morning, and add one more catheter- 
 ization for each additional 2 ounces of urine up to six times daily. 
 When the required number of catheterizations exceeds this limit, 
 some other form of treatment is urgently demanded, even though 
 catheterism appears to maintain the patient's general health. 
 
 Catheters for use in cases of enlarged yrostate should be 14 to 16 inches 
 long. If there is difficulty in introducing the usual soft rubber catheter, 
 it is possible usually to insert a Mercier catheter; this is one made of 
 webbing, like the English catheter (p. 958) , but having the point set at an 
 angle of 110 degrees with the shaft (Fig. 958, 1 ) . This elbow facilitates 
 the point of the catheter riding over the prostatic obstruetion, the 
 point of the instrument being made to follow the roof of the urethra. 
 A double elboived catheter may be useful at times. If neither of these 
 can be inserted, an English catheter, moulded to the proper "prostatic 
 curve," as advised at p. 959, may be used. If it will not pass without 
 
ENLARGEMENT OF THE PROSTATE 1035 
 
 the stylet, it should he reiutroihiced with the ox-er-curxcd styh't in its 
 interior; wUvw the ohstrnetion is met, the stylet may he withdrawn 
 uhout halt' an inch, thus raising; the point of the instrument over the 
 obstruetion (I'hysick. ISIS) (Fig- 95S, 'A). A metal prostatic catheter 
 is ad\isal)Ie only where the tissues are so hard and resistant from 
 lon>;-stanilin<2; inflannnation, that flexible instruments are not strong 
 enough to ])ush apart the sclerosed structures. If the i)atient has to 
 catheterize liimself a metal catheter never should be allowed; the best 
 instrument is the soft rubber catheter, next the Mercier or the Eng- 
 lish. The ])atient should be drilled freciuently in the necessary aseptic 
 techni(iue, care of the catheters, and their introduction. Only intel- 
 ligent and careful patients, willing to devote the necessary time to 
 the matter, will succeed in avoiding the prompt occurrence* of cystitis, 
 which is eventuallv nearlv inevital)le. 
 
 Fig. 958. — Prostatic catheters: 1. Mercier's coude (elbowed) catheter. 2. Bi-coude, 
 or double elbowed catheter. 3. English catheter mounted on an over-curved stylet; 
 when the stylet is partly withdrawn the catheter assumes the form indicated by the 
 dotted lines. 4. Metal catheter, with prostatic curve. 
 
 Besides the occurrence of cystitis, the treatment of which is dis- 
 cussed at p. 9()3, certain other complications are not unusual. Acute 
 complete retention of urine is treated by immediate catheterization. 
 There is great danger in delay, and the chance of the retention being 
 overcome by palliative measures is very much less than in cases of 
 acute retention from stricture. In chronic complete retention of urine 
 the bladder should be drained by a permanent catheter, in the hope 
 that the cause is atony of the bladder, which may be relieved by con- 
 stant drainage. If retention persists after atony has been relieved in 
 this way, or if atony is not relieved by the drainage, it will be advisable 
 either to remove the prostate or to establish a suprapubic vesical 
 fistula (see below). The treatment of residual urine (chronic incom- 
 plete retention of urine, without distention of the bladder) has been 
 considered at p. 1034. Finally there may be retention with overflow 
 (chronic incomplete retention of urine with distention of the bladder) : 
 here immediate and complete withdrawal of the urine from the bladder 
 is considered inadvisable, since experience has showai that sudden 
 relief of intravesical pressure usually is followed by hematuria from 
 rupture of veins in the bladder walls, and is frequently followed by 
 the development of surgical kidneys, uremia, coma, and death, within 
 
1036 SURGERY OF THE URETHRA AND PROSTATE 
 
 a few days. It is prol)able that the danger in such cases hes in the 
 intermittent catheterization that has usually been employed, since 
 this increases the chances of infection, and since Cabot (1908) showed 
 that constant drainage by the use of an inlying catheter was able to 
 avert threatening fatalities from such causes. Hence the surgeon 
 either should adopt Cabot's plan or should adhere to the time-honored 
 custom of evacuating such over-distended bladders by degrees, with- 
 drawing only a few ounces at a time; or if all the urine is drawn 
 at once, and an inlying catheter is not retained, he should replace 
 most of the fluid withdrawn from the bladder by saline solution. 
 
 Among palliative operations the formation of a suprapubic fistula 
 holds first place. This was popularized in 1S88 by Hunter jMcGuire; 
 the operation resembles that of su})ra]>ubic cystotomy (p. 970). 
 Where urethral obstruction is marked, there is no likelihood of the 
 suprapubic fistula closing, but when this tendency is observed a rubber 
 tube should be worn constantly in the fistula. At the time of the 
 operation any calculi present may be removed, but no attempt should 
 be made to remove the prostate in such feeble patients as those for 
 whom this jjalliative operation is advisable. Siter (1912), however, 
 has found that dilatation of the vesical orifice of the urethra, by the 
 insertion of the surgeon's finger through the suprapubic wound, may 
 secure almost as much relief (even if only temporary) as a formal 
 prostatectomy, and may be resorted to without materially prolonging 
 the operation or increasing its gravity. If a pedunculated prostatic 
 out-growth is found acting as a ball-valve against the vesical orifice 
 of the urethra, it should be removed; if no other urethral obstruction 
 exists (a point readily determined by passing a soft catheter) this 
 may effect permanent relief of all symptoms. In some cases where 
 the prostate is small and atrophic, and the bladder thickened and 
 contracted, much relief may be secured by median perineal cystotomy, 
 with incision of the prostate and dilatation of the prostatic urethra 
 (perineal prostatotomy) ; a perineal tube is retained until a permanent 
 fistula is assured. After either suprapubic or perineal drainage a fair 
 measure of continence is secured; and constant drainage by an in- 
 lying catheter will be available whenever demanded by the occurrence 
 of cystitis. 
 
 The Bottini operation was introduced in 1874, but little used until 
 popularized by Freudenberg in 1897. It consists in making incisions 
 in the prostate by a galvano-cautery introduced through the urethra. 
 The subsequent cicatrization and contraction of these incisions may 
 reduce the size of the prostate and thus overcome urinary obstruction; 
 or they may fail to do so. The operation is uncertain in its results, 
 the good effects sometimes secured are not permanent, and the mor- 
 tality is no lower than that of prostatectomy in skilled hands. 
 
 3. Radical Treatment consists in removal of the prostate. It is 
 the treatment of choice, and should be adopted in every case ex-cept 
 where distinct contraindications exist. The chief contraindications 
 are severe cystitis and renal insufficiency; and these usually may be 
 
I'liOSTATECTOMY 
 
 1037 
 
 overcome by preliminary treatment, wliicli may inehulc some of the 
 palliative operations already discussed, notably sui)rapubic drainage 
 of the bladder. Extreme age is not a contraindication, but if such 
 patients can be kept comfortable by catheter life, it will not be 
 advisable to resort to prostatectomy. 
 
 Two methods of operation are in common use: the suprapubic, 
 introduced in 1887 by McGill of Leeds, and improved and popularized 
 in 11)01 by Freyer, of London; and the jjeriiiral, which was a gradual 
 development of the i)ractice of perineal prostatotomy (a common 
 practice in the early part of the last centur\), and which was employed 
 first in cases of malignant disease during the decade from 1870 to 
 1880. Its modern de\'elopment is due largely to the labors of the 
 French school, headed by Albarran, and to its exi)loitation in this 
 country by Dr. II. II. Young, of Johns Hopkins University. 
 
 /h6o-j:>ro5ta^ic //.^amenJ 
 
 J^er/'toneum 
 
 oneurosls °/I?fi/2onuil^f.ers 
 
 jrostate 
 Ant. lai/er "/ Tr^a/i^ular /ijament 
 
 Fig. 959. — Sheath of prostate in sagittal section (diagrammatic). (Deavcr and 
 
 Ashhurst.) 
 
 For cases of enlarged prostate of the adenomatous type (the immense 
 majority) suprapubic prostatectomy (Freyer) is preferable; but where 
 the prostate is dense, and adherent to surrounding structures, and 
 where the bladder is small and contracted, the operation is best done 
 through the perineum, as it will be impossible to shell out the organ 
 as is done in the suprapubic operation. , 
 
1038 
 
 SURGERY OF THE URETHRA AND PROSTATE 
 
 Suprapubic Prostatectomy. — The prostate lies upon the triangular 
 ligament and above the aponeurosis of Denonvilliers (Fig. 959); 
 neither of these structures, so important in completing the floor 
 of the pelvis, is divided when the prostate is lifted off them and 
 delivered into the cavity of the bladder. When the prostate is adeno- 
 matous its enucleation in this manner is accomplished with surprising 
 
 ^ecto-Desical fascia "^'-^s^s^v. 
 Jst.Di. vision ^^^ j \ 
 ,2 /id. Dtuisfon ^ j 
 3rd. Division ^ 
 
 06lurator 
 Intemi/.s 
 
 Analjascicc- 
 ZeoaforAni 
 
 \ \ vessels Smrue: 
 
 Fk 
 
 960. — Sheath of prostate in transverse section. Line of section shown in the 
 lower drawing (diagrammatic.) (Deaver and Ashhurst.) 
 
 ease. The enlarged prostate projects into the bladder, and is covered 
 only by mucous membrane or at most by attenuated muscular tissue 
 which is as much prostatic capsule as it is vesical wall. Enucleation 
 takes place theoretically between the proper prostatic capsule (con- 
 densed by the eccentric enlargement of the "prostatic tumors") 
 
SUPRA rCJilC r HOST A TKCTOM Y 
 
 irno 
 
 and its slicatli, fonnrd by partitions of tiie rectovesical fascia (Fi^. 
 [){')()). It is not unlikely, however, that in many cases the enucleation 
 takes place within the layers of the true prostatic capsule, much as the 
 heart of an onion may be shelled out, leaviiifj the outer layers intact. 
 Tlic bladder is opened as in snpra])nl)ic cystotomy (j). 070), and to 
 assist subsequent manipulations the index and middle fingers of one 
 hand (gloved) are passed into the patient's rectum (the sj)hincter hav- 
 ing been well stretched previously) and are made to push the i)rostate 
 u]) toward the su])raj)nl)ic wound (Fig. WW ). The surgeon then inserts 
 a finger of the other hand into the ^•esical orifice of the urethra, and 
 breaks through the mucous membrane covering the enlarged prostate. 
 The natural line of cleavage is found without much trouble. The 
 
 Fig. 9(31. — Suprapubic prostatectomy. 
 
 finger should first pass to the outer side of the lateral lobe first attacked, 
 since here the attachment of the prostate to its sheath is least dense. 
 Then the finger cautiously but not timidly works down under the 
 lateral lobe toward the neighborhood of the posterior commissure 
 and the ejaculatory ducts. Next the posterior and inferior surfaces 
 are separated from the sheath; and finally when the lobe is pretty well 
 outlined the finger may pass along the lateral and inferior surfaces 
 to the apex of the lobe and free this from the triangular ligament. 
 At times the lateral lobe first attacked comes away alone, leaving 
 the urethra still attached to the other lobe. More often the vesical 
 mucous membrane tears during this enucleation, and the vesical 
 orifice of the urethra becomes entirely detached by extension of the 
 tear across the trigone of the bladder. Then the enucleating finger 
 
1040 
 
 SURGERY OF THE URETHRA AND PROSTATE 
 
 will pass across to the other lobe, beneath the posterior commissure 
 of the prostate. Finally, when enucleation of the second lobe has 
 been completed, the prostate is found fully detached from surrounding 
 structures, except where the urethra annexes it to the triangular 
 ligament. At this stage it is said the prostatic urethra may slip out 
 of the prostate, remaining attached to the triangular ligament; but 
 what usually occurs is that it tears off just on the vesical side of the 
 verumontanum, and is removed with the prostate. The anterior 
 commissure of the gland may give away during these manipulations, 
 but in most cases the prostate is removed in one mass (Fig. 9()2). 
 It is then withdrawn from the bladder, and the cavity from which 
 it has been enucleated rapidly contracts. Bleeding rarely is alarming, 
 and usually is rapidly controlled by hot douching.^ The bladder is 
 then closed around a large drainage tube, as in cases of suprapubic 
 cystotomy. The tube may be removed in four or five days, and the 
 patient may leave his bed as soon thereafter as proves agreeable to 
 him. The bladder is irrigated once daily through the suprapubic 
 wound as long as this remains open. Should it show no tendency to 
 close by the third week, a catheter should be passed once daily by the 
 
 Fig. 962.— Eiihirw'd prostate nniovcd l,y 
 urethra pointing tovvurd blailder. Prostate (^n 
 
 ii|>ia])ubic prostatectomy. Catheter in 
 it-b inferior surface. Episcopal Hospital. 
 
 urethra. Removal of the prostatic urethra will have shortened the 
 urethral channel considerably, the vesical orifice now being close to 
 the triangular ligament. Stricture formation is unusual. The chief 
 dangers are shock and hemorrhage. The immediate mortality varies 
 from 5 to 7 per cent, in skilled hands, and the results are exceedingly 
 good. Voluntary urination is restored; no residual urine remains; 
 and the patient's life is lengthened by many years. 
 
 Perineal Prostatectomy I think is best reserved for small fibrous 
 prostates. The best exposure is gained by the technique of the French 
 school, elaborated by Proust (1903). The patient lies on his back with 
 his buttocks raised on a sand pillow, and thighs flexed on the abdomen 
 as far as possible, thus inverting the pelvis and bringing the perineum 
 nearly horizontal. A staff is fixed in the urethra, and through a trans- 
 verse incision, with convexity forward, extending from one ischiatic 
 tuberosity to the other, the perineal centre is exposed. Then the 
 attachment of the external sphincter ani to this is divided, and the 
 
 1 In cases of persistent bleeding the bed of the prostate may be packed with 
 gauze, held in place by a few sutures of catgut passed through the free edges of 
 mucous membrane forming the roof of the cavity. One end of the gauze projects 
 from the suprapubic wound, and the packing can thus be removed as soon as the 
 catgut sutures are absorbed (Deaver and Ashhurst). 
 
PERINEAL PROSTATECTOMY It 141 
 
 dissection contimicd i)()stori()r to the transverse perineal nuiseles. 
 By (Irawinji the anns toward the eoeeyx, the reeto-urethralis muscle 
 is put on the stretch; and hy dividin*,' this close to the inenihranous 
 urethra (which is not opened), the surgeon opens the si)ace between 
 the two layers of the apcMieurosis of Denonvilliers (Fig. 959), known 
 as the ''espacr drrullahlr rftroprosfatique.'' The rectum now falls 
 away from the anterior structures and ai)pears like a loop of intestine 
 floating free in the peritoneal cavity; it is covered by the posterior 
 layer of this aponeurosis, while the anterior layer still covers the pros- 
 tate and seminal vesicles. It is to be recalled that the aponeurosis 
 of Denonvilliers really is an obliterated sac of peritoneum, analogous 
 to the processus vaginalis of the testicle. 
 
 Beyond the anterior layer of the aponeurosis of Denonvilliers the 
 prostate can now be indistinctly felt, floating away as soon as touched. 
 The urethra therefore is opened, at the apex of the prostate; a pros- 
 tatic tractor is inserted into the bladder, and its blades are turned so as 
 to catch on the vesical surface of the prostate. The prostate being thus 
 steadied, its sheath (anterior layer of the aponeurosis of Denonvilliers) 
 is opened over one of the lateral lobes of the prostate, by an incision 
 parallel to the urethra. By the finger or a blunt dissectc.r, this sheath 
 is then stripped from each lateral lobe, with utmost thoroughness. 
 Proust says that time apparently lost at this stage of the operation 
 will be found to accelerate matters considerably at a later stage. 
 When the prostate is thus freed of all its attachments except to the 
 urethra and ejaculatory ducts, the prostatic tractor is removed, and 
 the floor of the urethra is split open from the apex of the prostate 
 back to but not into the neck of the bladder. This cut hemisects the 
 prostate as well, and each lateral lobe in turn is dissected oft' the lateral 
 and upper aspects of the urethra, by scissors. If possible, each lateral 
 lobe is removed entire, not by morceUement. Proust ligates the ejac- 
 ulatory ducts, thinking this lessens the chances of orchitis. The bladder 
 is drained by rubber tube, and the floor of the prostatic urethra is 
 sutured over this as a guide, as far forward as the triangular ligament, 
 where the tube emerges. The perineal wound is drained by gauze 
 wicks, and is partly closed by buried sutures. 
 
 Young introduced in 1903, and has practised in a large series of cases 
 with surprising success and wonderfully low mortality, an operation 
 which he calls "conservative" perineal prostatectomy. The technique 
 is much the same as that of the French school, except that an attempt 
 is made to preserve the ejaculatory ducts by leaving intact the pos- 
 terior commissure of the gland, in which they run. It seems very 
 doubtful whether this feature of the operation is of any value. 
 
 Atrophy of the Prostate and Contracture of the Neck of the Bladder 
 (Chetwood, 1901).— Usually these occur together, and are the result 
 of long continued inflammatory changes. The sclerotic type of pros- 
 tatic enlargement, already described, can with diflficulty be separated 
 from atrophy of the gland. The symptoms are similar to those seen 
 in enlargement of the prostate, since the sclerosis of the ti.ssues inter- 
 feres with urination. Especially frequent, according to Young, are 
 66 
 
1042 SURGERY OF THE URETHRA AND PROSTATE 
 
 chronic inflammatory changes in the prostatic utricle. Another fre- 
 quent factor in urinary obstruction in these cases is a "bar at the neck 
 of the bladder" (Guthrie, 1834) usually in the form of a dense fibrous 
 ring around the vesical orifice of the urethra. Chronic prostatitis 
 usually coexists. The diagnosis is made by recognizing the small 
 sclerotic prostate on rectal examination, and by use of the cystoscope 
 which usually shows an abnormal condition of the prostatic urethra 
 and vesical neck. 
 
 Treatment. — Treatment even by specialists in genito-urinary sur- 
 gery-, is not always satisfactory. The condition of the urine should 
 be attended to; and methods already advised in cases of chronic 
 prostatitis may be tried. Best results follow direct treatment of the 
 prostatic urethra through the cystoscope. If a bar at the neck of the 
 bladder is found, it may be punched out by one of the modern instru- 
 ments copied after Mercier's original prostatotome and prostatectome 
 (1837), or relief may be secured by the Bottini galvano-cautery opera- 
 tion. Prostatectomy (by the perineal route) may be considered the last 
 resort. 
 
 Carcinoma of the Prostate is now recognized as much more frequent 
 than formerly supposed. It probably occurs in not less than 10 per 
 cent, of patients who complain of symptoms of urinary obstruction 
 from prostatic disease. The malignant growth appears to originate 
 usually in that portion of the prostate posterior to the urethra and 
 below the ejaculatory ducts. It tends to infiltrate upwards invading 
 the vasa deferentia and seminal vesicles long })efore it spreads into 
 the prostatic tissues immediately adjacent to the neck of the bladder. 
 Patients seldom come under observation while the growth is still 
 operable. In some cases the earliest indication of trouble is not the 
 occurrence of local symptoms, but the discovery of metastasis in the 
 bones of the pelvis, trunk, or thighs. Usually it is found that a hard, 
 nodular, fixed tumor occupies the region of the prostate, and that the 
 rectal mucous membrane does not glide easily over the enlarged organ 
 as is the case in benign enlargement. Peferred pains are frequent in 
 advanced cases. 
 
 Treatment. — Treatment usually must be palliative. A radical oper- 
 ation, involving removal of the prostate and seminal vesicles, resection 
 of the neck of the bladder, and suture of the membranous urethra to 
 the remaining vesical wall, has been devised and practised by Young, 
 with fair success. Where such a radical operation is impracticable, he 
 has practised a partial perineal prostatectomy with preservation of the 
 urethra and vesical mucosa; he thinks that in about 60 per cent, of 
 cases excellent functional results may be expected Avhich will be 
 maintained so long as the patient lives. 
 
 Sarcoma of the Prostate is rare. A tumor in a child or yoimg person 
 probably is sarcomatous; it grows very rapidly, and almost always is 
 inoperable. The earliest symptom often is complete retention of 
 urine; less often do symptoms of incomplete urinary obstruction 
 occur, or rectal symptoms. Death occurs within three months to 
 two years. 
 
CHAPTER XXVIII. 
 SURGERY OF THE MALE GENITAL ORGANS. 
 
 SURGERY OF THE PENIS. 
 
 Congenital Deformities. — Hpyospadias. — Tlie most frequent of these 
 is hypospaciias, in wliich there is a defect in the floor of the urethra, 
 extending from the meatus a variable distance backward. It occurs 
 once in about 8()() males, and is due to failure of coalescence 
 between the two lateral portions of the penis on its under surface. 
 In glandular hypospadias the urinary meatus is displaced only slightly, 
 and unless it is as low as the region of the frenum no treatment usually 
 is required. In penile hypospadias (Fig. 963) the opening usually occurs 
 at the junction of tlie penis and scrotum (peno-scrotal hypospadias) 
 but mav be anterior to this site. In the most marked deformity the 
 
 ^M 
 
 r > '"■^ ^ " 
 
 H^l^^^^^^^l 
 
 ^H 
 
 ■ 
 
 P 
 
 Xk 
 
 ^ 
 
 ••^^i^f-'"'- -" 
 
 
 
 "^ 
 
 Fig. 963. — Penile hypospadias. Episcopal Hospital. 
 
 opening is in the perineum, there is usually cleft scrotum, the penis is 
 rudimentary, and there is resemblance to the condition known as 
 hermaphrodism. In all cases of hypospadias there is downward 
 incurvation of the penis, and the prepuce usually is abnormal in form 
 or attachment. 
 
 Treatment. — Treatment involves some form of plastic operation, 
 and the best time for this is about the age of six years. It is very 
 important to employ only such skin in plastic operations as will remain 
 free from hair throughout life. In most cases the bladder should be 
 drained through the perineum during the first week after operation, 
 or until the sutured structures have firmly united. In glandular 
 
1044 
 
 SURGERY OF THE MALE GENITAL ORGANS 
 
 hypospadias Beck's operation (1907) is the best (Figs. 964 and 9()")) : the 
 urethral orifice and about an inch of the urethra are dissected free, and 
 
 Fig. 964. — Beck's operation for hypospad- 
 ias. (Watson and Cunningham.) 
 
 Fig. 
 
 965. — Beck's operation, 
 and Cunningham.) 
 
 (Watson 
 
 the glans is perforated from base to summit by a bistoury, this tract 
 is dilated, and the previously mobilized urethra is drawn through and 
 
 the meatus sutured in its normal posi- 
 tion. A similar operation may succeed 
 when the urethral opening is in the penis 
 not too far from the glans; but in most 
 cases of penile and in all cases of peno- 
 scrotal and perineal hypospadias, it is 
 necessary to construct a new urethra by 
 skin flaps. A good method in cases of 
 peno-scrotal hypospadias is to outline 
 two corresponding rectangular flaps from 
 the under surface of the penis and the 
 anterior median raphe of the scrotum, re- 
 spectively, as indicated in Fig. 9(i6. The 
 denuded edges are sutured together, 
 and after several weeks, when union is 
 firm, the penis with the adherent scrotal 
 raphe (which forms the floor of the new 
 
 urethra) are cut free from the scrotum, and 
 Fig. 966. — BueknaU's operation for ^i ^ ] • i r ]• 
 
 penoscrotal hypospadias (1907). the raw surtaccs are covered m by slidmg 
 
CONGENITAL DEFOh'MiriF.S OF THE PENIS 
 
 i()4r) 
 
 flaj>s t(),i;;('tluT From the sides, or hy l)riii<;iii<f the rcduiidaiit i>r('|)ucc oxer 
 the under surt'acc ol" the j)eiiis as a l)rid^e. After a ])eiiile iiretlira has 
 been eonstructed in this way, it max he transphmted into the glans, 
 aeeording to BiH'k's operation, on a snhsecpient oeeasion. C'antas 
 (1911) used a plastic llaj), with ])edie]e, Iroin the thi^di, eontaininj^ a 
 section of the h)nii; saphenous \-ein, which serxcd as the new urethra. 
 
 -Epispadias; age six y 
 
 Ki)iseopal Hospital. 
 
 Epispadias. — In epispadias the roof of the urethra is deficient for 
 a greater or less distance back from the normal site of the meatus 
 (Fig. 9()7). It is treated by operations analogous to those employed 
 for hypospadias. Cantwell's operation (1895) is commended by 
 Binnie (Fig. 968). 
 
 Fig. 968. — Cantwell's operation for epispadias: a new urethra is formed by inverting 
 skin-flaps; the corpora cavernosa are then separated in the mid-line; the new formed 
 urethra is placed in the floor of the channel thus made; and finally the cavernous bodies 
 are sutured together over the new urethra. 
 
 Hermaphrodism. — This is a condition in which an individual pos- 
 sesses the generative organs of both sexes. It is excessively rare; in 
 the vast majority of cases only false hermaphwdism exists: a male 
 with a perineal hypospadias, cleft scrotum, rudimentary penis, and 
 undescended testicles may resemble a female on casual inspection; or a 
 female with abnormally large clitoris and congenital absence of the 
 vagina may resemble a male hypospadiate. Treatment involves opera- 
 tive cure of the predominant deformity, when this is possible. 
 
 Phimosis. — Phimosis is the condition in which the prepuce cannot 
 be retracted over the glans. It is rare as a congenital deformity, most 
 
1046 
 
 SURGERY OF THE MALE GENITAL ORGANS 
 
 Fig. 969. — Phimosis. Age sixteen years. 
 Episcopal Hospital. 
 
 cases so classed being merelj' instances of adherent prepuce the result 
 of balano-posthitis : in these retraction is possible, though difficult. 
 Cure follows daily retraction, cleansing, and application of zinc oxide 
 ointment to the inflamed parts. Most cases of true phimosis (Fig. 969) 
 are the result of neglect of the parts in infancy and early childhood, 
 
 the preputial orifice re- 
 maining infantile in size 
 while the penis has con- 
 tinued to grow. Mere 
 i'lungation or redundancy 
 of the prepuce usually is 
 congenital (Fig. 970). In 
 man}' cases phimosis de- 
 velops as a temporary 
 condition in adult life, 
 as a complication of bal- 
 ano-posthitis from chan- 
 croids or gonorrhea. 
 
 Treatment. — Treatment 
 may be by incision, ex- 
 cision, or circumcision. 
 Incision (dorsal slit of the 
 prepuce) was mentioned at p. 1008; it is used mostly in cases com- 
 plicating balano-posthitis. Excision of a wedge shaped portion of the 
 prepuce is seldom or never employed. Circumcision is the typical 
 operation. Various special forceps have been devised to simplify the 
 operation but their place is readily supplied by clamping the foreskin 
 between the handles of a pair of scissors, the redundant foreskin being 
 cut off with another pair (Fig. 971). The section should be made 
 obliquely, removing more 
 tissue from the dorsum of 
 the penis than from the 
 region of the freniun. The 
 clamp should be applied 
 at a level which corre- 
 sponds with the sulcus be- 
 hind the corona glandis, 
 and the skin should be 
 drawn well in front of the 
 glans before the clamp is 
 tightened. ^Yhen the re- 
 dundant tissue is cut away 
 and the clamp- is removed 
 
 it will be found that the skin surface of the prepuce retracts, while 
 its mucous layer still covers the glans. The mucous layer is then 
 slit up the dorsum, with scissors, as far as the corona glandis. It is 
 not necessary to trim off the triangular flaps of mucosa thus formed, 
 as by careful suturing no redundant tissue is left. Next ewry bleeding 
 
 Wmh^ 
 
 Fig. 970. 
 
 -Redundant prepuce. Children's 
 Hospital. 
 
CIRCUMCISION 
 
 1047 
 
 })()int shoiihJ he raiK/lit in hinnostafs and iKjatcd with fine caff/nf. Xcf^Icct 
 of this procaiitioii usually results in t'orinatiou of a hematoma and 
 hreakin*; down of the wound. Finally the skin and mucous layer of 
 the i)repuee are sutured to<ijether with interrupted sutures of chromic 
 cat";ut. The first suture is introduced at the frenum, the second in 
 
 Fig. 971. — Circumcision with two pairs of scissors. Episcopal Hospital. 
 
 the mid-line on the dorsum of the penis, the third and fourth at the 
 midpoints on the right and left sides, and such other intervening 
 sutures as are required to secure neat apposition. The ends of all 
 these sutures are left long after tying, and the dressing (a thin roll of 
 gauze) is held in place by knotting the free ends of the sutures over it 
 
 Fig. 972. — Dressing for circumcision. Episcopal Hospital. 
 
 (Fig. 972). This roll of gauze should be applied a little slack, so as not 
 to produce strangulation should erections occur. No other dressing is 
 used. In the course of ten days or two weeks this gauze may be 
 peeled off, as the chromic catgut sutures will have been absorbed. In 
 the meantime the seat of operation requires no treatment. 
 
1048 
 
 SURGERY OF THE MALE GENITAL ORGANS 
 
 Paraphimosis. — Paraphimosis is the coiKhtion in which the foreskin 
 has been retracted over the ghms and cannot he replaced owinji; to 
 swelling of the glans or edema of the foreskin (Fig. 97.'^). The tightest 
 band of constriction, back of the corona, may become ulcerated from 
 pressure; this always occurs before there is danger of strangulation 
 of the penis. 
 
 Treatment. — In recent cases it is usually ])ossible to reduce the 
 paraphimosis by pushing the glans upward with the thumbs, while 
 the index and middle fingers of both hands, applied behind 
 
 the corona, pull the foreskin 
 forward. If reduction is not 
 accomplished in this way, it 
 is often advised that the con- 
 stricting band be divided; but 
 as a matter of fact usually no 
 treatment is required beyond 
 bathing the parts in hot water 
 and keeping the penis elevated 
 to favor reduction of the 
 edema. In the course of a 
 few days the foreskin can be 
 drawn down again in most 
 cases, but sometimes perma- 
 nent thickening from lymph- 
 edema persists and may re- 
 cjuire excision or circum- 
 cision. 
 Balanitis and Balano-posthitis. — Balanitis is inflammation of the 
 glans penis; posthitis is inflammation of the pre])uce. Usually both 
 glans and prepuce are inflamed (balano-posthitis). In children this 
 condition is a frequent complication of adherent prepuce; in adults 
 it occurs as a complication of gonorrhea or chancroids, being predis- 
 posed to by phimosis or elongation of the prepuce. In the aged, 
 formation of a preputial calculus is an occasional complication.^ 
 
 Treatment. — In cases with phimosis or adherent prepuce, dorsal 
 incision of the prepuce, or circumcision should be done, the former 
 being preferable in gonorrheal or chancroidal cases. Inflammation 
 may be reduced before and after operation by instillations of weak 
 silver nitrate solution between glans and prepuce. 
 
 Herpes Progenitalis. — Herpetic vesicles sometimes dcA-elop on the 
 penis, especially on the mucous layer of the prepuce; they may occur 
 seemingly spontaneously, or soon after coitus. The vesicles resemble 
 those seen in cases of herpes occurring elsewhere on the body. The 
 
 Fig. 973. — Paraphimosis from gonorrhea; nine 
 days' duration. Episcopal Hospital. 
 
 1 Under the name of "the fourth venereal disease" Corbiis and Harris (1909) 
 have described a form of erosive balanitis due to symbiosis of a spirochete and a 
 vibrio. The spirochete is identical with that of Vincent's angina, found in the 
 mouth, and the infection is believed to be conveyed to the prepuce and glans by 
 unnatural sexual practices. 
 
CAh'ClXO.MA OF Till': I' EN IS 
 
 1049 
 
 iillVctioii appciirs first ms one or scNcnil inimitc reddish pjijjiilcs w liicli 
 turn into M-siclcs in the conrsc ol" :i IVw hours. Often they assume a 
 crescentic outhne. There is some itehiuji; and tinji;nn<^, and after the 
 \esieles rui)ture contact witli the urine causes hurnin;,' pain. Patients 
 usually are subject to recurrinj; attacks. 
 
 Treatment. The u'cneral health sjiould l)e ^n\-en attention, and any 
 local source of irritation (j)himosis, etc.) should be a])pr()j)riately 
 treated. If the herpetic \esicles are kept clean and dry, they usually 
 heal within a few days. Astrin<j;ent washes {\ \)vv cent. suli)hate of 
 zinc, or acetate of lead) should be applied once daily, the parts beinj^ 
 then thorou<ihIy dried, and powdered. 
 
 Fig. 974. — \'onoreal warts from phimosis. Duration seven months. No voneri-al 
 disease. Episcopal Hospital. 
 
 Venereal Warts (Verrucae Acuminatse). — This affection was men- 
 tioned at p. 259. It has no necessary connection with venereal dis- 
 ease. The warts usually occur in persons wdth phimosis or redundant 
 ])repuce, and are the result of uncleanliness (Fig. 974). 
 
 Treatment. — In mild cases it is sufficient to apply caustics (fuming 
 nitric acid) every day or so until the warts shrivel up and drop off; 
 but in cases complicated by phimosis this should be relieved by 
 appro])riate means, and the warts should be excised and their bases 
 cauterized. 
 
 Carcinoma. — Carcinoma is the only tumor of frequent occurrence 
 on the penis. It may develop in an old venereal scar; is predisposed 
 to by the existence of phimosis or balano-posthitis;i but often no 
 cause is evident. It presents the same characteristics as carcinoma 
 in other regions of the body. Usually it arises on the glans or the 
 prepuce. The squamous-celled type is not highly malignant. A papil- 
 lary form is more usual, is much more malignant, and presents irreg- 
 ular projections, resembling venereal warts except for the hardness 
 of their bases and margins, and the presence of ulceration, which 
 occurs early. The inguinal lymph nodes on both sides are involved 
 early in the papillary variety, not until later in the squamous-celled 
 type of carcinoma. Invasion of the pelvic nodes also occurs. 
 
 Treatment. — If the carcinoma has not spread beyond the glans, 
 amputation of the penis is sufficient; but if the corpora cavernosa have 
 
 * Leukoplakia of the glans is recognized as a pre-cancerous condition. 
 
1050 SURGERY OF THE MALE GENITAL ORGANS 
 
 become infiltrated extirpation of the entire penis is necessary. In all 
 cases the inguinal lymph nodes should be excised; usually this may 
 be done at the same time as the operation on the penis, and then always 
 as the first step of the operation; but if the tumor is very septic, it is 
 best to postpone removal of the inguinal lymph nodes until the lower 
 wound has healed. 
 
 Amputation of the Penis involves removal only of the phallic portion 
 of the penis: a rubber tube is tied around the base of the organ, to 
 control bleeding; a circular incision is made through the skin well 
 behind the seat of disease, and the skin is allowed to retract. The cor- 
 pora cavernosa are then divided at the base of the skin-flap and closed 
 transversely by sutures. The urethra (with the corpus spongiosum) 
 is dissected free for a centimeter or more in front of this point, and is 
 divided. "The urethra is then slit up in three places, one below and 
 two above; the three square fla})s so formed are then turned back and 
 their corners cut off. This makes three small triangular flaps which 
 when spread out form one large triangle. The skin is then sutured 
 accurately to the edges of this triangle, and no raw surface is left" 
 (G. G. Davis, 1897). 
 
 Extirpation of the Penis. — The scrotum is slit open from the peno- 
 scrotal juncture to the perineum, and the bulbous urethra is isolated 
 and divided, and its vesical end fixed to the skin of the perineum, 
 being split on its under surface for at least half an inch. The incision 
 is next carried around the base of the penis, the suspensory ligament is 
 divided, the crura cut, and the entire penis is removed. A catheter 
 is left in the bladder. In advanced cases it is necessary to remove both 
 testicles and spermatic cords as far as the internal abdominal ring, 
 so as to permit complete extirpation of the inguinal lymphatics. 
 
 SURGERY OF THE TESTICLES, SCROTUM, AND SPERMATIC 
 
 CORD. 
 
 Congenital Anomalies. — In some rare cases one or botli testicles 
 may l)e absent. A much more usual anomaly is non-descent of the 
 testicles, on one or both sides, called respectively monorchidism and 
 cryptorchidism. The affection is more frequent on the right. The 
 testicle may be retained in the abdominal cavity or may be lodged 
 in the inguinal canal or at the external ring. Inguinal hernia often 
 is present as a complication. Rarely the testicle is misplaced, being 
 found in the perineum or on the thigh. In most cases the diagnosis 
 of non-descent or misplacement is readily made by observing the 
 absence of the testicle from the scrotum, and its presence in the ingui- 
 nal canal or elsewhere. Sometimes the testicle is loandering, slipping 
 up into the inguinal canal when the cremaster contracts, and at other 
 times remaining in the scrotum (Figs. 975 and 976). 
 
 Treatment. — ^A testicle which remains in the inguinal canal or at 
 the external ring is constantly exposed to injury; one which comes and 
 goes dilates the inguinal canal and predisposes to the development 
 
UNDESCENDED TESTICLE 
 
 1051 
 
 of hernia, and is itself liable to torsion (see below). The condition 
 should be remedied by operation, and the best age for this is about 
 six years. The undescended testicles, according to Corner, possess 
 the power of producing spermatozoa only for a short time, usually 
 from the age of twenty to twenty-two years, though their function 
 of internal secretion may be sufficient to ensure the acciuirenient 
 of secondary sexual characteristics at the usual age of puberty. In 
 any case, their removal is contraindicated unless they are actually 
 diseased. The main therapeutic indication is to place the testicle 
 in a situation where it shall not l)e exposed to injury. If possible it 
 should be brought down into the scrotum; but if this cannot be done, 
 it should be replaced within the abdominal cavity.' The operation 
 is begun by opening the inguinal canal, as in the hernia operation. 
 The testicle is exjHJsed, and a hernial sac if present is excised and the 
 opening in the i)arietal peritoneum is closed. If the cord is not long 
 enough to enable the testicle to be replaced in the scrotum, it often 
 
 Fig. 975. — Wandering testicle : testicle 
 now in inguinal canal. Age fifteen years. 
 Episcopal Hospital. 
 
 Fiit. 97G. — Wandering tcaticle: testicle 
 now in upper part of scrotum. Epis- 
 copal Hospital. 
 
 is possible to lengthen it (Bevan, 190.'^) by careful division of fibrous 
 bands and freeing the structures well around the internal ring, by 
 ligation and division of the cremasteric artery, or even by excision 
 of all the constituents of the cord except the vas and its accompany- 
 ing vessels; the latter step seldom is necessary, but according to Bevan 
 sacrificing the spermatic vessels will not lead to gangrene of the tes- 
 ticle. ^Yhen the organ has been brought down into the scrotum, 
 it should be fixed by sutures to the median scrotal septum. The 
 cord should not be transplanted as in the Bassini hernia operation, 
 but should be treated as in Ferguson's method (p. 792). 
 
 1 The supposition that a mal-placed testicle is more prone to the development 
 of malignant tumors than the normally situated organ, is cited b}' some as justifica- 
 tion for orchidectomy (castration) in these ca.ses. But this supposition rests on 
 inconclusive facts; and even if it were true, it would not be the mal-position which 
 created the predisposition to malignant disease, but some developmental defect 
 in the organ itseK and the occurrence of mahgnant changes would be no more fre- 
 quent if the testicle were retained in the abdomen than if it were replaced in the 
 scrotum. 
 
1052 
 
 SURGERY OF THE MALE GENITAL ORGANS, 
 
 Torsion of the Testicle, generally traumatic in origin (straining 
 efi'orts, contortions of the body, etc.), occurs usually in children with 
 unduly mo\'able testicles. In most cases the tunica vaginalis extends 
 up to the internal ring, and congenital hydrocele (p. 105S) may be 
 present. The symptoms are acute, sickening ])ain in the inguinal canal 
 or scrotum according to the site of the testicle; the testicle becomes 
 a little swollen, and is extremely tender. The diagnosis must be made 
 from strangulated inguinal hernia and from inflamed hydrocele of 
 the cord. In these conditions a normally placed and symptomless 
 testicle usually is present. Treatment is by operation, which consists 
 in uncoiling the twist and fixing the testicle in normal position by 
 means of sutures; or in castration if gangrene of the testicle has 
 occurred. 
 
 Inflammation of the Testicle. — Orchitis implies inflammation of 
 the testis proper; while inflammation of the ejjididymis is called 
 
 epididymitis. In most cases 
 both component parts of the 
 testicle are affected (epidi- 
 dymo-orchitis) , but almost 
 in\arial)ly one or the other 
 affection dominates the clin- 
 ical picture. Apart from 
 traimia, which is not a very 
 frequent cause, the disease 
 is oftenest due to infection 
 carried by the blood-stream 
 (orchitis) or extending from 
 the urethra through the vas 
 deferens (epididymitis). Or- 
 chitis is much more fre- 
 quent in boys than in adults, 
 and occurs as a complication 
 of mumps (Fig. 977), tonsil- 
 litis, influenza, etc. The at- 
 tack lasts about four days. 
 Usually the right testis is 
 affected, but occasionally both sides are attacked one after the other. 
 Some atrophy may occur subsequently. Suppuration often occurs in 
 cases complicating typhoid fever. Epididymitis usually is a compli- 
 cation or sequel of gonorrhea, occurring from the third to the sixth 
 week of the disease. Sometimes it occurs after the passing of a sound 
 or catheter, especially in cases of prostatic enlargement. The left side 
 is affected oftener than the right, but both sides may be involved 
 in turn. 
 
 Symptoms. — Symptoms of orchitis and epididymitis are of rather 
 sudden onset, but prodromes (malaise, headache, nausea, creepiness, 
 and chilliness) may occur. The earliest symptoms may be referred 
 to the abdomen, and may be mistaken for those of appendicitis. 
 
 Fig. 977. — Urchins I'ullowiag muiiipb. Age 
 fourteen years. Mumps one week ago, followed 
 first by left orchitis, which subsided; then by 
 right orchitis, which has lasted for three days. 
 Episcopal Hospital. 
 
ORCHITIS AM) J'JJ'IDIUYMJTIS 1053 
 
 The tosticlr hecoincs acutely j)aiiifiil, cxccssixcly tender, and swollen; 
 most of the swellinj^ is due to inflammatory ell'usion into the tunica 
 vaj^jinalis (artitc hi/drorrlc). The scrotum may become red and edema- 
 tous. The temperature sometimes is hij^h, and the patient may 
 appear very ill, at least for a time. If the patient keeps on his feet, 
 and particularly if the testicle is allowed to hanj,' unsupported, all 
 the symptoms are agi^ravatcd, and there may he drafitginj; abdominal 
 pains. The diagnosis between orchitis and epididymitis may be made 
 by noting the history of the case and the probable cause of the scrotal 
 swelling; by observing that in epididymitis the swelling begins in the 
 globus minor, si)reads to the globus major, and that when the entire 
 epididymis is ati'ected it forms a "boat-shaped" enlargement on the 
 outer and back part of the testis. Most of the scrotal enlargement, 
 as already remarked, is caused l)y acute hydrocele of the tunica vagi- 
 nalis. In orchitis the smooth globular form of the testicle is felt, and 
 the e])i(li(lymis is not palpably enlarged. 
 
 Treatment. — The patient should be put to bed, and the scn^tum 
 elevated. Heat, especially in the form of a flaxseed poultice, is better 
 than cold as a local application. If injections have been in use, for 
 gonorrhea, they should be stopped. Some urinary antiseptic should 
 be given. Puncture of the tense tunica albuginea in one or several 
 places, with a fine tenotome, is the most efficient way of relieving 
 pain. No anesthetic is required. The scrotum is painted with 2 per 
 cent, iodin solution, and is drawn tensely over the testicle, and the 
 puncture is made at the seat of greatest swelling. This plan is said 
 to have been suggested by Petit, and widely employed by Vidal de 
 Cassis, and by H. Smith, during the last century. As an open oper- 
 ation the method has been recently revived by Bazy, Belfield, and 
 Hagner; for this, a general anesthetic is advisable: the tunica vaginalis 
 is incised, its contents evacuated, and the inflamed epididymis is punc- 
 tured in one or several places; the scrotal wound is then packed with 
 gauze. If no operation is done acute symptoms begin to subside in 
 four or five days ; then sorbef acient ointments, especially those contain- 
 ing guaiacol and ichthyol, should be applied, and when only a painless 
 induration remains resolution may be favored by strapping the testicle 
 with adhesive plaster or with a broad strip of rubber tissue. In the most 
 acute cases of gonorrheal epididymitis suppuration may occur, requir- 
 ing incision and drainage of an abscess; occasionally castration is 
 reciuired. In almost all cases cicatricial changes occur in the body 
 or globus minor of the epididymis, which prevent discharge of semen 
 into the vas deferens; and if both sides have been affected the patient 
 may be rendered sterile. To overcome this condition, which is said 
 to occur in about 40 per cent, of cases of bilateral epididymitis, Edward 
 Martin (1902) has practised with success an anastomosis between the 
 globus major and the vas deferens (epididymo-vasostomy). Cases of 
 recurrent epididi/mitis often are caused by infection from the seminal 
 vesicles, and can be cured only by proper treatment of this focus of 
 infection. 
 
1054 SURGERY OF THE MALE GENITAL ORGANS 
 
 Neuralgia of the Testicle. — Under this name is described a condi- 
 tion in which the testicle, usually the left, is persistently tender and 
 afflicted with lancinating pains. This condition must be distinguished 
 from referred pain due to lesions elsewhere, notably renal calculus 
 and varicocele. If no cause for referred pain exists, and a history of 
 epididymitis, or orchitis is obtained, it is probable that the neuralgia 
 is due to compression of the testicle by sclerosis and contraction of 
 the tunica vaginalis or albuginea; under such circumstances continu- 
 ance of palliative measures (use of a suspensory, hot and cold douches, 
 occasional passage of a cold sound, or instillations of argyrol into the 
 deep urethra, etc.) probably will prove useless, and it is best to expose 
 the testicle and excise the tunica vaginalis. 
 
 Semino-vesiculitis or Spermato-cystitis. — This may be acute or 
 chronic. The acute form almost invariably occurs as a complication 
 of gonorrhea. Chronic semino-vesiculitis usually is a" sequel of the 
 acute form, but the condition may be chronic from the start and may 
 be due not to gonorrhea but to non-gonococcic posterior urethritis or 
 prostatitis. In most cases only one vesicle is affected at first, but 
 the second rarely escapes eventual infection. In the acute form the 
 vesicle is distenderl with purulent exudate, but inflammatory infil- 
 tration of surrounding tissues may occur to such a degree that the 
 vesicles cannot be recognized by palpation through the rectum. The 
 symptoms of the acute form are pain in the perineum or rectum, 
 especially after defecation or seminal ejaculation. The semen often is 
 blood-stained, and may be colored blue from the admixture of indigo. 
 Sexual excitability is pronounced, and frequent and painful erections 
 are characteristic. In the chronic form the symptoms are those of 
 the gleet fp. 1011); recurrent attacks of epididymitis often occur. 
 
 Treatment. — In acuie semino-vesiciilifis the patient should be con- 
 fined to bed, and all local treatment of the urethral condition should 
 be discontinued. A hot water bag may be applied to the perineum, 
 or hot rectal injections may be given if they lessen discomfort. Urinary 
 antiseptics should be given, and the bowels should be opened by a 
 laxative. If pain is excessive, and particularly if constitutional symp- 
 toms exist, the occurrence of suppuration should be suspected: the 
 patient then should be anesthetized and the rectum explored; if any 
 signs indicating suppuration are found, the vesicle should be exposed 
 through the perineum (by the method advised for perineal prosta- 
 tectomy), opened and drained. The treatment of chronic semino- 
 vesiculitis has already been considered in connection with chronic 
 urethritis. In cases of recurrent epididymitis, Belfield opens the vas 
 deferens below the external abdominal ring and irrigates the seminal 
 vesicle by injecting not more than 2 c.c. of the irrigating fluid. As 
 noted at p. 472, Fuller drains the seminal vesicles through the 
 perineum in cases of gonococcic arthritis. 
 
 Tuberculosis of the Testicle. — This probably is caused in inost 
 cases by hematogenous infection. Keyes, however, maintains that 
 it is always secondary to tuberculosis of the prostate and seminal 
 
TUBERCULOSIS OF THE TESTICLE 
 
 1055 
 
 vesicles. The lesion in the testicle begins in the <,'l()l)us major of the 
 epididymis^ and invades the testis seconchirily. The ])ati('nts nsnally 
 are between twenty and thirty years 
 of age, and as a rule only one tes- 
 ticle is afl'ecte<l at first, but exten- 
 sion to the other side is freciuent, 
 probably by way of the seminal vesi- 
 cles and ejaculatory ducts through 
 the vas deferens. 
 
 Symptoms. — The onset usually is 
 insidious, and the ])atient may be 
 scarcely aware of his condition until 
 he discovers by accident a hard 
 nodule in the epididymis, or until 
 supi)uration has occurred with 
 fistulization of the scrotum. In 
 the rare cases with acute onset 
 the condition at first somewhat 
 resembles gonorrheal epididymitis; 
 but unlike this aHection it does not 
 subside in the course of a week 
 or two. In most cases the clini- 
 cal diagnosis must be considered 
 uncertain until areas of softening 
 
 have formed; usually this is quickly followed by implication of the 
 skin of the scrotum, which becomes adherent to the testicle (Fig. 
 
 978) ; then the cold abscess 
 ruptures and cheesy pus is 
 constantly discharged from the 
 fistula (Fig. 979) . At this stage 
 the diagnosis may be confirmed 
 bv finding tubercle bacilli in 
 
 Fig. 978. — Tuberculosis of both tes- 
 ticles, duration four months; age nine- 
 teen years. Right testicle adherent to 
 skin, and abscess palpable. Both 
 seminal vesicles enlarged and nodular. 
 Episcopal Hospital. 
 
 the discharge; at earlier stages 
 focal reaction to a tuberculin 
 test may be relied on. 
 
 Treatment. — There is much 
 dispute among surgeons as to 
 the proper treatment of these 
 patients. Some advise imme- 
 diate castration in all cases; 
 others condemn all operative 
 interference and trust entirely 
 to hygienic measures and vaccine therapy. ^ly own feeling is that 
 so long as suppuration and fistulization do not occur there is no need 
 to remove the testicle. A nodule in the epididymis may remain 
 unchanged for years provided excellent hygienic life conditions are 
 
 Fig. 979. — Tuberculosis of left testicle, 
 duration two years; age thirty-three years. 
 Operation for left hydrocele eighteen months 
 ago; fistulte in scrotum for last six months. 
 (See Fig. 980.) Episcopal Hospital. 
 
 In gonococcic epididymitis the globus minor is attacked before the globus major. 
 
1056 
 
 SURGERY OF THE MALE GEXITAL ORGANS 
 
 present, as has been shown l)^ Watson and Cunningham. Under such 
 circumstances (and if tuberculous lesions exist elsewhere in the body, 
 even if the local lesion is advanced) minor operative measures may be 
 of benefit to the local condition and may promote the patient's com- 
 fort. Epididymectomy sometimes is 
 done, leaving the testis intact, with 
 or without anastomosis between it 
 and the vas deferens. According to 
 Barney (1911) the semen is sterile in 
 So per cent, of patients even before 
 epididymectomy. A cold abscess may 
 be treated on the same principles 
 recommended when dealing with cold 
 abscesses in association with bone 
 disease. But when fistulization has 
 occurred, and particularly if secondary 
 infection is present, I feel quite sure 
 it is best, especially in the average 
 hospital patient, to remove the testicle 
 and spermatic cord as far as the 
 internal ring. The operation is de- 
 scribed below. If only one testicle is 
 diseased and is removed, only about 
 9 per cent, of patients die of genito- 
 urinary tuberculosis, the other testicle 
 becomes involved subsequently only 
 in about 26 per cent., and cure fol- 
 lows in about 45 per cent, of patients; 
 if double castration is necessary, 15 per 
 cent, of patients die within the first 
 three years after operation, but 56 per 
 cent, are permanently cured (Haas). 
 Castration or Orchidectomy. — Open the inguinal canal, as in the 
 operation for hernia. Transfix and ligate the spermatic cord at the 
 internal abdominal ring. Cut the cord below the ligature and turn 
 it down over the scrotum with its annexed fatty tissue and lymph 
 nodes. Close the inguinal wound (except at the lower angle where 
 the cord emerges) as in the operation for hernia, and cover it with 
 sterile gauze. Then proceed to remove the testicle in one mass with 
 the adherent scrotum, by extending the original incision downward, 
 cutting wide of all infiltrated tissue. In this way the inguinal wound 
 runs no risk of being infected, since it is closed before the suppurating 
 scrotal tissues are attacked, and all the diseased tissue is removed in 
 one mass. Usually it is well to leave a small drain in the scrotal end 
 of the incision for a couple of days. 
 
 Syphilis of the Testicle. — Sarcocele.' — Sarcocele is a manifestation 
 of the third stage of syphilis. The lesion almost always is in the 
 
 1 This is an old term still in use, signifying a fleshy or solid tumor; by long usage 
 it is applied exclusivel}' to enlargements of the testicle. 
 
 Fig. 980. — Specimen removed by 
 castration from the patient shown in 
 Fig. 979: testicle and adherent skin 
 of scrotum, with spermatic cord and 
 inguinal lymph nodes in one mass. 
 Episcopal Hospital. 
 
SARCOCELE 
 
 1 ().")( 
 
 Fig. 981. — Scars frf)ni doiihlo orfhidoctoniy for 
 tuberculous sarcocclc. Age forty-six years. Epis- 
 copal Hospital. 
 
 testis, not in tlio (•i)i(li(lymis; the most frequent form, elinically, is a 
 gummatous deposit in one or several si)ots. I'alliologieaily a diU'use 
 sclerosis of the tunica alhuginea and septa of the testis is a very fre- 
 quent lesion, l)ut it is seldom reco<,niized c-linicall\'. In most cases 
 of the jiinnmatous form 
 of the disease only one 
 testis is involved; soften- 
 ing of the gumma with 
 ulceration of the skin 
 scarcely ever occurs. The 
 affection is extremely in- 
 dolent. The testicle grows 
 slowly and never reaches a 
 \ery large size; it presents 
 smooth, rounded nodules 
 almost of woody hardness 
 and not at all tender. If 
 the epididymis is involved 
 the testis feels like a 
 stone lying in a clam shell, 
 the sharp edges of the 
 hardened epididymis em- 
 bracing the testis (Keyes). 
 
 Frequently a hydrocele of the tunica vaginalis is present. The only 
 subjective symptoms are those due to the increased w^eight of the 
 organ. A history of syphilis usually can be obtained ; the Was.sermann 
 test will be positive ; and antisyphilitic treatment will prove rapidly 
 curative. The diagnosis must be made from tuberculosis and from 
 
 tumors of the testicle. In the 
 former the epididymis is af- 
 fected, and invasion and fistuli- 
 zation of the skin are frequent. 
 In the latter, most of which 
 are instances of malignant 
 disease, the testicle grows 
 rapidly, attains a much greater 
 size than in syphilis, there is 
 more pain and discomfort, 
 and invasion of the skin is 
 frequent, with the protrusion 
 of a fungus growth. 
 
 Treatment. — In every case of 
 sarcocele, where the diagnosis 
 is doubtful, it is well to try 
 antisyphilitic treatment before any operation is recommended. If 
 the disease is syphilitic, mixed treatment will be quickly effectual. 
 
 Neoplasms of the Testicle are not very rare, except benign tumors. 
 ]\Iost of the tumors are extremely malignant, and are classed loosely 
 67 
 
 Fig. 982. — Sarcoma of right testicle. Age 
 seventy-four years, duration five months. 
 Diagnosis made after tapping hydrocele (four 
 ounces of bloody fluid), which permitted pal- 
 pation of hard nodular growths. Episcopal 
 Hospital. 
 
1058 
 
 SURGERY OF THE MALE GENITAL ORGANS 
 
 as sarcomas. Chevassu (1910), in a careful study of 100 cases, found 
 carcinoma (seminoma) in 47, true sarcoma in 3, and mixed tumors in 
 50 cases. Such tumors may occur at any age, but are most frequent 
 in middle life. Growth is rapid (weeks), and the tumor may become 
 several times as large as the normal testicle. In most cases hydrocele 
 of the tunica vaginalis develops, and its contained fluid usually is 
 blood-stained (Fig. 982) : if there is no history of injury the presence 
 of blood in hydrocele fluid always suggests malignancy. Extension 
 occurs early along the spermatic cord, and to the lumbo-aortic 
 lymph nodes, and especially to a lymph node at the bifurcation of 
 the common iliac vein. 
 
 Treatment. — By the ordinary method of castration, as described 
 in connection with tuberculosis of the testicle, surgery succeeds in 
 saving about 20 per cent, of patients.^ Radical oi^eration implies re- 
 moval of the tumor in one mass with its anatomically related lymph 
 nodes. Chevassu has devised a technique by which the lumbo-aortic 
 nodes may be reached: the incision passes along the inguinal canal 
 and up the abdominal wall outside the semilunar line as far as the 
 false ribs, and if necessary is extended forward along the costal border. 
 The parietal peritoneum is dissected inward, without opening the 
 peritoneal cavity, and when the perirenal fascia is reached its anterior 
 layer is incised, and the dissection continued in front of the kidney, 
 
 until the renal vessels and 
 aorta are exposed. In 1910 
 Chevassu collected records 
 of 11 such operations, with 
 no immediate mortality; in 
 8 the operation was carried 
 to a successful conclusion, 
 but in 3 others had to be 
 abandoned (inoperable) . 
 
 Hydrocele. — This is a col- 
 lection of serous fluid in the 
 tunica vaginalis. 
 
 In congenital hydrocele 
 (Fig. 983) there is a com- 
 munication between the tu- 
 nica vaginalis and the peri- 
 toneal cavity, Usuall\' the orifice of communication is too small for 
 the development of a hernia. The condition is noted first in infancy, 
 but may persist until adult life, even without the development of a 
 hernia. When the scrotum is elevated the fluid disappears within the 
 abdominal cavity, usually very slowly, and as slowly reappears when 
 the erect posture is resumed. Treatment is the same as for inguinal 
 hernia in infants. 
 
 ^ Out of 100 patients with malignant disease of the testicle treated by the ordinary 
 method of castration, Chevassu found 81 died in less than four years, while 19 
 survived in good health for periods varying from four to ten years after operation. 
 
 Fig. 9!S3. — Congenital hydrocele (left). Age five 
 months. Children's Hospital. 
 
HYDROCELE 
 
 1059 
 
 Fig. 984. — Hydrocele of the right tunica 
 vaginalis, in a child of three years. Chil- 
 dren's Hospital. 
 
 Acquired Hydrocele of tlie tunica vaginalis is seen oftenest in cliild- 
 liood and in middle adult life (Figs. i)S4 and 085). The pathogenesis 
 of the lesion is uncertain, but the fluid probably is in the nature of an 
 exudate, due to trauma or some form of infection of low grade. As 
 already mentioned, gonorrheal epididymitis and most other infections 
 of the testicle are accompanied 
 by the development of acute hy- 
 drocele, and such a lesion may 
 lay the foundation for the sub- 
 sequent pathological change in 
 the serous membrane which 
 leads to chronic serous effusion. 
 It is possible that many adult 
 hydroceles are unrecognized 
 manifestations of tuberculosis 
 (Fig. 979) or syphilis. In some 
 cases rice bodies are found, and 
 the sac may become calcareous. 
 Most of the adults affected are 
 arteriosclerotic. 
 
 Symjjfoms. — The swelling commences at the bottom of the scrotum, 
 and gradually increases in size. At first it is soft and fluctuating, 
 but eventually may become very tense and hard. The patient has 
 little or no discomfort except from the size and weight of the swelling. 
 Usually relief is sought before a very great size is attained. Rarely 
 the sac extends into the inguinal canal, and from the existence of con- 
 strictions (similar to those 
 encountered in some cases of 
 inguinal hernia — see p. 781) 
 an hour-glass or bilocular hy- 
 drocele may result (Fig. 986). 
 The same appearance may be 
 caused by the coexistence of 
 a vaginal hydrocele and a 
 hydrocele of the cord. 
 
 The diagnosis is made from 
 the history of the case, and 
 from observing that most hy- 
 droceles are translucent when 
 examined by transmitted light; 
 old hydroceles, with thickened 
 walls, and those into which 
 hemorrhage has occurred, 
 from hernia was considered 
 
 Fig. 985. — Hydrocele of tunica vaginalis. 
 Age fifty-two years; duration nine years; 
 tapped eight times. One quart withdrawn 
 after making photograph. Episcopal Hospital. 
 
 however, are opaque. The diagnosis 
 at p. 783. 
 
 The best treatment is by operation; but in adults who refuse operation 
 or in whom operation is contraindicated for any reason, it is sufficient 
 to withdraw the fluid from time to time by tapping the hydrocele. 
 
lOGO 
 
 SURGERY OF THE MALE GENITAL ORGANS 
 
 Fig. 9SG. — Bilocular hydrocele. 
 Age twenty-three years; duration 
 since infancy. (Dr. C. F. Mitchell's 
 case.) Pennsylvania Hospital. 
 
 The testicle almost always is at the back part of the swelling, hut its 
 position should be ascertainerl by palpation and by examination with 
 transmitted light. The tumor is then grasped in the left hand, and 
 the skin is drawn tightly over it, when with a quick thrust a trocar 
 
 and cannula are pushed into the most 
 prominent part of the swelling, avoid- 
 ing large veins. The trocar is then 
 withdrawn and the contents of the 
 hydrocele allowed to flow. When all 
 the fluid has been evacuated the can- 
 nula is withdrawn and the puncture is 
 sealed with cotton and collodion. No 
 anesthetic is required and the patient 
 need not be confined to bed. He should 
 wear a close-fitting suspensory in an 
 endeavor to prevent too rapid re-ac- 
 cumulation of the fluid. It is well to 
 examine the testicle carefully after the 
 hydrocele fluid has been evacuated, 
 as in many cases it is found diseased. 
 Some surgeons recommend the injec- 
 tion into the emptied sac of some 
 irritating or caustic fluid in the hope 
 of causing obliteration of the cavity; but the alleged advantages of 
 this practice do not compensate for the dangers of uncontrollable 
 inflammation and excessive pain. In most cases in which simple tap- 
 ping is done, re-accumulation of the fluid occurs at progressively 
 shorter intervals. 
 
 Oyerution. — In most cases, especially in children and young adults, 
 it is best to resort to operation. The incision should be made just 
 below the external abdominal ring, not in the scrotum, as this is diffi- 
 cult to sterilize. The operation most often done, known by the name 
 of Jaboulay (1895), consists in evacuating the contents of the sac by 
 incision, and everting the icalls of the tunica vaginalis around the testicle 
 so that the serous surface of the tunica vaginalis lies against the sub- 
 cutaneous tissues. If the incision in the tunica vaginalis is made just 
 large enough to push the testicle through, no sutures are required to 
 hold the everted tunica vaginalis in place; this is known as the "bottle 
 operation." I have had one recurrence after this operation in a child, 
 and know of others; and, therefore, prefer excision of the sac (von 
 Bergmann). In cases with much thickening of the tunica vaginalis 
 it is well to scrape the testicular portion of the tunica vaginalis with 
 Volkmann's sharp spoon, as it cannot be removed with the knife 
 Avithout damage to the testicle. 
 
 Hydrocele of the Cord is a collection of serous fluid in an unoblit- 
 erated portion of the funicular process of peritoneum. If the sac 
 communicates with the peritoneal cavity, the condition is known as 
 funicular hydrocele; if the sac is closed at both ends, it is an encysted 
 
VARICOCELE 
 
 1001 
 
 Fk;. 987. — -Encysted hydrocele of 
 the cord. Age two and a half years. 
 Children's Hospital. 
 
 In/(lnirrlr nf the cord ( Fij;. i)N7). Ili/drorcle of ffir c(in(il of Xurl: is tlie 
 c'orrcspondiiijf coiiditioii in the female sex. If iiiflimiiiiatioM of the sac 
 occurs from any cause, and no accurate history can he ol)tainc(l, the 
 condition may he reachlx' mistaken 
 for stran<iulated hernia. Trcafnwnf 
 of hydrocele of the cord consists in 
 excision of the sac. 
 
 Spermatocele. — Spermatocele, 
 known also as encysted hydrocele of the 
 tunica vaginalis, is a cyst whicli 
 de\elops aliout the globus major 
 of the epididymis and contains 
 spermatic fluid. Its pathogenesis is 
 disputed. It occurs oftenest in 
 young adults, and forms a slowly 
 growing but tense cystic tumor 
 at the upper and back part of the 
 testicle. It may project into the 
 tunica vaginalis or grow behind it. The diagnosis often is not madt^ 
 until operation is done. Proper treatment is excision of the sac. 
 
 Hematocele. — A collection of blood in the tunica vaginalis may 
 result from injury or disease; there may or may not have been a pre- 
 existing hydrocele. In many cases seemingly of spontaneous origin, 
 hematocele is symptomatic of malignant disease of the testicle. The 
 physical signs are the same as those of vaginal hydrocele, except that 
 the swelling is opaque to transmitted light. 
 
 Treatment. — In acute traumatic cases the blood should be with- 
 drawn by tapping. In other cases the treatment is that of the 
 underlying cause (hydrocele, sarcocele). 
 
 Varicocele. — A varicose condition of the veins of the spermatic 
 cord (the pampinniform plexus) occurs in about 10 per cent, of males, 
 usually commencing about the age of puberty. In almost all cases 
 the left side is affected, occasionally both sides, very seldom the right 
 alone. This predilection for the left side is attributed (1) to the pres- 
 sure of the sigmoid on the spermatic vein; (2) to the fact that the left 
 spermatic vein enters the left renal at a right angle, while the right 
 spermatic enters the vena cava obliquely; (3) to the absence of valves 
 on the left side; (4) to the lower position of the left testicle in the 
 scrotum; and (5) to the habit most men have of "dressing left." 
 Seldom or never can any exciting cause be found. The rather rapid 
 onset of a varicocele usually is symptomatic of some abdominal 
 neoplasm obstructing the venous circulation. 
 
 Symptoms. — Symptoms may be entirely absent even in cases where 
 the varicocele is very large. Often, however, the patient complains 
 of vague dragging pains and discomfort in the left side of the scrotum, 
 and there may be occasional lancinating pains in the testicle and along 
 the cord. Atrophy of the testicle is mentioned as a possible sequel, 
 but I never observed it. In rare cases the patient may be "neuras- 
 
1062 
 
 SURGERY OF THE MALE GENITAL ORGANS 
 
 thenic." Examination shows a relaxed state of the scrotum, with 
 the left testicle hanging very low, and above it, extending up to the 
 inguinal canal, a soft mass of dilated veins which feel like a bunch 
 of earthworms (Fig. 988). These veins may be emptied by having 
 the patient lie down and elevating the scrotum; they will become 
 distended again when he stands up, even if pressure is made over the 
 inguinal canal. 
 
 Fig. 988. — Varicocele, age thirty-six years. Episcopal Hospital. 
 
 Treatment. — Treatment seldom is required. There is nothing serious 
 in the condition and it often disappears spontaneously later in life. 
 If the patient is uncomfortable he will feel better for wearing a sus- 
 pensory bandage, particularly in warm weather. Cold douches 
 sometimes are soothing. If marked discomfort persists, the varicocele 
 is easily cured by a simple operation. An incision is made just below 
 the external abdominal ring, and the cord is brought out of the wound. 
 The dilated veins are separated from the vas deferens and its accom- 
 panying vessels, and the varicose veins are ligated close to the external 
 ring, and again about two inches lower. The ends of these ligatures 
 are left long, and after the section of veins lying between the ligatures 
 has been removed, the ligature on the proximal end is tied to that on 
 the scrotal end of the cord, thus shortening the cord and elevating 
 the testicle. The wound is closed without drainage (careful hemo- 
 stasis), and the patient stays in bed a week or ten days. 
 
 Elephantiasis. — Elephantiasis occurs oftenest in the scrotum, as 
 pointed out in Chapter XI, and the disease may spread thence to the 
 penis. As the result of lymphatic obstruction and repeated attacks 
 of dermatitis, the skin and subcutaneous tissues become enormously 
 hypertrophied, deep creases and folds form, and in them dirt and 
 macerated epithelial cells collect, emitting nauseating odors, and pre- 
 disposing to ulceration and renewed attacks of dermatitis, eczema, 
 erysipelas, etc. In tropical countries the scrotum may become so 
 immense that the patient has to push it around before him on a wheel- 
 barrow. In this latitude the disease is very seldom seen. The best 
 
TUMOIiS OF THE SCROTUM 
 
 1063 
 
 trcaiiiicnt is excision. 'I'lic operation may prove didicult, and l)lee(l- 
 inj:; usually is free; hnt it' asepsis can he maintained, great relief is 
 alliirdcd. 
 
 Tumors of the Scrotum are unusual. The occurrence of dermoids 
 (seciuestration cysts) was mentioned in Chapter IV (Fig. 78). 
 Papillomas are more fre(iuent, and often undergo malignant degen- 
 
 FiG. 989. — Ulcerating papilloma of .scrotum (epitheliomatous). Age thirty-six 
 years; duration three and a half years. Episcopal Hospital. 
 
 eration (Fig. 989). In former years epithelioma of the scrotum was 
 frequentl}^ seen in chimney sweepers, from the irritation of the soot 
 which accumulated on the scrotum in these persons of none too cleanly 
 habits. At the present day workers in tar and paraffin are subject 
 to the same affection. The proper treatment of these tumors is 
 excision; this scarcely ever requires castration, as the malignant 
 growth spreads widely in the skin before attacking the testicles. 
 
CHAPTER XXIX. 
 
 SURGERY OF THE FEMALE GENITALS. 
 
 General Remarks on Examination of the Female Pelvic Organs. 
 — Position of the Patient. — The woman usually is examined in the 
 ''lithotomy position," that is, lying on her back, with knees and hips 
 flexed, and the soles of the feet resting on the bed or table where she 
 lies (Fig. 990). Sometimes the ''Sims position" is preferred: here the 
 woman lies on her left side, with her left arm behind her back, thus 
 throwing her right shoulder forward; her right thigh is flexed upon 
 her abdomen as fully as possible, so that the right knee rests upon 
 the table, while tlie left lower extremity is flexed onlv to a moderate 
 
 Fig. 990. — Lithotomy position. (Findley.) 
 
 degree (Fig. 991). Sometimes, but not very often, it is desirable to 
 examine the patient in the standing position, or even in the knee- 
 chest position (Fig. 992). In a virgin, vaginal examination should 
 be made only when the patient is under the influence of a general 
 anesthetic. A rectal examination may suffice. 
 
 An examination of the female pelvic organs should include (1) 
 inspection of the external genitalia, (2) examination icith the speculum, 
 and (3) bimanual examination of the internal genital organs. The 
 bladder and rectum should be empty. 
 
EXAMIXATJOX OF THE FEMALE I'ELVIC ORCIAXS lOGo 
 
 External Genitalia.— Note the conditioii of the lahia: iiiHanimatory 
 cliaiiiics, as in acute ^^HKK'occic \ulvitis and vaginitis; the cxisti'iice 
 of a labial abscess; the presence or absenee of mucous patches; edema 
 from i)regiiaiicy or jjclvic tumors; excoriations and hypertrophy in 
 cases of pruritus. Observe the state of the hymen; the position of the 
 
 Fig. 991. — Front view of Sims' position. (Findley.) 
 
 carunculae myrtiformes, if present; and the condition of the vulvar 
 opening, whether normally closed or widely gaping as in multiparous 
 patients with relaxed vaginal outlet. The position and condition of 
 the urethral orifice should be noted, especially the presence of a 
 gonorrheal discharge, or the existence of a caruncle. 
 
 Fig. 992. — Knee-chest position. (Findley.) 
 
 Speculum Examination. — If the patient is in the Sims position, the 
 
 (hick-hill vaginal speculum of Sims (1845) should be used (Fig. 993, 2). 
 This is inserted with the blade in the sagittal plane, and as soon as 
 
1066 
 
 SURGERY OF THE FEMALE GENITALS 
 
 the vagina is entered the blade is turned transversely, and is pushed 
 forward until the stem catches on the fourchette; then the speculum is 
 drawn backward, displacing the posterior vaginal wall and rectum into 
 
 Fig. 993. — 1, Bivalve vaginal speciilum. 2, Sims' duck-bill speculum. 
 3, Speculum forceps. 
 
 Fig. 994. — 1, uterine sound. 2, sharp uterine curette. 3, dull uterine curette. 
 4, placental forceps. 5, double tenaculiun forceps. 6, cer\ical dilator. 
 
EXAMINATION OF THE FEMALE PELVIC ORGANS 10G7 
 
 the liollow of tlie sacrum, and causing tlic vagina to he hallooned with 
 air. This usually renders tlie cervix visihlc. In the dorsal and lithotomy 
 positions it is more convenient to use a bivalve speculum (Fig. 993, 1): 
 this is inserted closed, witii the blades in the sagittal plane; as soon 
 as the vagina is entered the speculum is turned transversely, but 
 the blades are not opened until the speculum has entered its full 
 
 Fig. 995. — Bimanual vaginal examination. (Dudley.) 
 
 length. When the blades are finally separated, the surgeon endeavors 
 to bring the cervix into view between them. If the speculum is too 
 small or too short this may prove difficult. Several sizes should be 
 available. TOen the cervix is exposed, examine its size, its shape, 
 and its position; note the presence or absence of lacerations, erosions, 
 ulcerations; observe the condition of the os, whether characteristic 
 
1068 SURGERY OF THE FEMALE GENirALS 
 
 of a nulliparous or parous patient; and especially note the presence 
 or absence of a cervical discharge and its character — mucous, purulent, 
 bloody, etc. In suspicious cases smears should be taken from vagina, 
 from urethra, and from cervix for microscopical examination. 
 
 Bimanual Examination. — After withdrawing the speculum, insert 
 two fingers of the glo\'ed hand into the \-agina. The beginner will 
 do best to use both right and left hands, alternately, on the same 
 patient; w^ith the left hand he will be able to feel lesions on the left 
 side of the pelvis which might easily escape detection if the right hand 
 only was used. First examine the condition of the posterior vaginal 
 wall and perineum. Then locate the cervix, and note its condition 
 (soft and characteristic of pregnancy; hard, with scar tissue from 
 previous pregnancies, lacerations, etc.), its size, its position (whether 
 or not displaced by pelvic lesions), and its mobilit}', or fixation. With 
 the aid of the other hand above the pubes (Fig. 995), then endeavor to 
 palpate the fundus of the uterus, and note its position, whether or not 
 it is displaced, whether movable or fixed, and finally the size and con- 
 sistency of the uterus. Note the presence or absence of a mass in the 
 pouch of Douglas; its consistency, fixation, and tenderness. Palpate 
 in turn each tube and ovary by passing the vaginal fingers first to one 
 side and then to the other side of the cervix, and endeavor to locate 
 and outline, between these and the fingers of the abdominal hand, 
 the uterine adnexa. No matter what the age, social condition, or 
 history of your patient, always exclude pregnancy before reaching a 
 final diagnosis. 
 
 Preparation for Operation and After-care. — Enough has been said 
 on this subject in Chapter XXII in reference to abdominal operations. 
 But a few words are necessary in regard to vaginal operations. It 
 is desirable to have all such patients in bed, and to have the parts 
 thoroughly cleansed by douching twice daily for several days before 
 operation. No operation should be done while the parts are acutely 
 inflamed, nor during a menstrual period unless immediate operation is 
 imperative. The bowels should be thoroughly opened by a purge given 
 early in the day before that set for operation, and a cleansing enema 
 should be given at least six hours before the time of operation (the 
 previous evening if necessary). If a purge is not given until the night 
 before operation, the bowels may be so loose as to move during the 
 operation and soil the wound. The bladder should be emptied just 
 before the operation. When the patient is in position on the table 
 the vagina is thoroughly washed with soap and hot water, wiped out 
 with alcohol, and douched with bichloride solution. 
 
 After operation the patient should remain in bed for at least two 
 weeks, often longer. The bowels should not be locked up by opiates, 
 and if they do not move by the fourth day castor oil should be given; 
 whenever possible an enema should be avoided. The urine should 
 not be drawn by catheter unless retention occurs; after the patient 
 has urinated the vulva should be gently douched with some hot 
 antiseptic solution and gently dried and powdered. 
 
rONG'EMTA L MA LFOh'MA TJOXS 
 
 lOOU 
 
 Congenital Malformations. Tlic \ ulva may Ik' congenitally imper- 
 forate, l)iit till' coiulitioii is more often due to adhesion ol' the lahia 
 minora as the result of vuKitis in eliildhood (V'\j^. !)!)()). In most eases, 
 whether eon.Ji;enital or aequired, the oeehidin}^ meml)rane is very thin, 
 and is n^adily rni)tiired l)y pulling the lal)ia apart or by ruj)turin<f 
 adhesions with a grooved director; oeeasionally the use of scalpel or 
 scissors is necessary. Reunion should he prevented hy dressing the 
 raw surfaces with horic acid ointment and the daily introduction 
 of a fold of lint. 
 
 Fig. 996. — Adhesion of labia from vulvitis in infancy. Age three years. 
 Children's Hospital. 
 
 Imperforate Hymen. — Imperforate hymen seldom is recognized until 
 after the age of puberty, when the non-appearance of the menstrual 
 flow% and its ultimate damming up in the vagina (hematocolpos) and 
 in the uterus (hematometra) cause a local examination to be made. 
 If these conditions continue unrelieved for several years a large pelvic 
 tumor may develop, and some danger exists of peritonitis from rupture 
 of the uterus or tubes or from leakage of the uterine contents through 
 the fimbriated extremity of the tubes. Treatment consists in incision 
 and drainage, and if necessary in some form of plastic operation to 
 ])revent cicatricial contraction. 
 
 Absence of the Vagina. — Absence of the vagina usuallx' is a congenital 
 defect, but occasionally the vagina becomes obliterated by cicatricial 
 contraction. If the presence of a uterus and adnexa can be demon- 
 strated (exploratory laparotomy may be necessary), attempts may be 
 made to construct a new vagina. \ arious external plastic operations 
 have been employed, but usually without permanent success. The 
 plan introduced by Baldwin (1907) though the mortality is higher, 
 has given much better results: a loop of the small intestine is excluded 
 from the intestinal tract, and still attached to its mesentery (which 
 must be sufficiently long) is sutured in place between bladder and 
 rectum, opening below at the ^allvar orifice, and being closed above 
 
1070 
 
 SURGERY OF THE FEMALE GENITALS 
 
 around the cervix uteri. The continuity of the intestinal tract is 
 then restored by end-to-end or lateral anastomosis. 
 
 Stenosis of the Cervix. — Stenosis of the cervix, usually from congenital 
 hypoplasia and accompanied by anteflexion of the uterus, is a frequent 
 cause of dysmenorrhea in girls and young women. The dysmenor- 
 rhea is of the obstructive type, that is, it is greatest preceding the flow 
 which often is delayed and usually is scanty. The patient usually is 
 sterile, and proper treatment often is followed by conception. The kink 
 in the uterus favors retention of secretions, and causes venous conges- 
 tion, with resulting endometritis. Examination shows an undersized 
 but lengthened (conical) cervix with pin-i)oint os, firm and unyielding 
 to the touch, and the fundus uteri close beneath the symphysis. 
 
 Treatment. — Forcible dilatation, the patient being anesthetized, is 
 seldom productive of permanent cure, even if the operation is many 
 times repeated. It is better to incise the cervix posteriorly in the 
 mid-line almost up to the internal os and recto-uterine fold of perito- 
 neum; a small wedge of tissue is cut out on each side (Fig. 997), and 
 
 Fi<j. 997. — Diulloy's operation for anteflexion. Patient in the Sims position. (Findley.) 
 
 the cut surface on each side is then folded on itself so as to pull the 
 anterior lip of the cervix backward {Dudley's operation, 1891). If the 
 anterior lip is very long it may be excised. Or Pozzi's operation may be 
 done: this consists in dividing the cervix bilaterally, hollowing out and 
 infolding upon itself each of the four denuded surfaces. 
 ■ Malformations of the Uterus. — Malformations of the uterus are not 
 very rare. Ectopic pregnancy may occur in one of the rudimentary 
 horns of a uterus bicornis. In cases of double uterus (uterus 
 didelphys) it is best, usually, to remove one uterus by hysterectomy, 
 to prevent complications during a possible pregnancy. 
 
 Gonorrhea in the Female. — As noted at p. 1071, the occurrence of 
 gonococcic infection of the genito-urinary tract in the female often 
 is not attended by very acute symptoms. The gonococci are deposited 
 at the vulvar orifice or in the vagina by mediate or immediate con- 
 tagion, and within a few days may produce acute urethritis, vulvitis, 
 
VULVITIS AND VAGINITIS 1071 
 
 and vaginitis. Fraiuciitly, howcNcr, no uciite symptoms <le\'elop, 
 hut tlie jj;()iioc()cci l()(lji;c and prolilerute in the vulvo-vaKinal glands 
 (Hart hoi in if iff) and in the cervical glands (endo-cervicitis) and are 
 exceedingly difficnlt to dislodge. When the disease reaches a chronic 
 stage, it persists indefinitely, causing no particular disahility at times, 
 hut at others j)roducing local and distant disturhances which render 
 life a hurden. iNloreover, the patient is a constant carrier of infection, 
 and this may he conveyed to innocent persons, especially children, 
 by mediate contagion. Recrudescences of the infection occur from 
 time to time, and with each new attack the germs travel higher in 
 the genital tract, spreading from the cervix to the uterus (endometritis), 
 where the infection does not linger, to the tubes, ovaries, and peri- 
 toneum; here occur acute and chronic salpingitis, jicJvic peritonitis, 
 pi/os(dpin.v, tnho-ovarian abscess, etc. These comi)lications frequently de- 
 velop first in the puerperium, especially after miscarriages or abortions. 
 
 Urethritis. — The urethra almost always is affected w^ien gonorrhea 
 attacks the female, but the course of the disease is much less acute 
 in its symptomatology, and residual foci of infection are much less 
 frequent than in the male. Occasionally a focus of infection remains 
 in the suhurcthral glands of Skene, but abscess formation is extremely 
 rare. These abscesses (one in each gland) protrude just below the 
 external urinary meatus, and pressure on them will make pus exude 
 from their orifices in the floor of the urethra, about 0.5 cm. within 
 the meatus. They should not be confused with urethral caruncles, 
 which are inflammatory hypertrophies or angeiomatous out-growths of 
 the urethral mucous membrane, protruding from the urinary meatus, 
 not beneath it through the anterior vaginal wall. Some caruncles 
 bleed or are excessi^'ely painful; such should be excised, with a wide 
 area of the mucosa from which they spring, as recurrence is frequent. 
 
 Treatment. — The treatment of gonococcic urethritis in the female 
 is subordinate to that of the vulvitis and vaginitis with which it is 
 accom])auie(l. 
 
 Vulvitis and Vaginitis. — These are exceedingly common in infants 
 and little girls, usually resulting from mediate contagion through soiled 
 towels, etc. In them the symptoms may be very acute, as is also the 
 case in the young nullii)ara, but in the case of women who have borne 
 many children the vaginal mucous membrane is much less easily 
 infected and gonococcic vaginitis is rarely seen. The patient complains 
 of burning pain, worse during urination and defecation; the labia 
 minora are red, edematous, and tender; there is a profuse purulent 
 exudate, in which gonococci are readily found; the vaginal walls may 
 be fiery red, and in rare instances exfoliation of epithelium and ulcer- 
 ation may occur. The vulvo-vaginal glands of Bartholin are exceed- 
 ingly prone to harbor the infection for a long time, and abscess forma- 
 tion is very common (Fig. 998) ; indeed it may be the first symptom to 
 bring the patient to a physician. The vulvo-vaginal abscess points 
 at the posterior part of the vulvar opening, between the labium majus 
 and minus, and is to be treated by early and free incision, with excision 
 
1072 
 
 SURGERY OF THE FEMALE GENITALS 
 
 of the anterior wall of the abscess sac, or if possil)le by extirpation 
 of the entire gland, as recurrence is very common unless radical 
 treatment is adopted at the first. Occasionally as the result of very 
 attenuated infection, or from cicatricial closure of the duct, a cyst of 
 Bartholin's gland develops (Fig. 999) ; this is to be treated by excision. 
 
 Fig. 998. — Abscess of the vulvo-vaginal 
 gland of Bartholin. Duration three 
 days. Acute gonorrhea in a patient aged 
 twenty-two years. Pennsylvania Hos- 
 pital. 
 
 Fig. 999. — Cyst of vulvo-vaginal gland 
 of Bartholin. Age thirty-six years ; dura- 
 tion fourteen years. Attached by two 
 pedicles to right labium minus. Episcopal 
 Hospital. 
 
 Treatment.— The treatment of acute gonococcic vulvitis and vag- 
 initis is best conducted with the patient in bed, until the most acute 
 symptoms subside. Great care must be taken to prevent infection 
 of the eyes, as well as conveyance of contagion to other patients by 
 instruments, dressings, etc. There is very little use in local treatment, 
 since injections, irrigations, etc., are very apt to spread the infection 
 further up the genital tract. The patient should be confined to liquid 
 diet at first, especially drinking plenty of water; urinary antiseptics 
 should be administered; and the accumulation and crusting of the 
 purulent discharge should be prevented by douching the vulva fre- 
 quently with hot permanganate of potash solution, or some other 
 antiseptic. The heat of the solution is beneficial in itself. It may be 
 well to leave a rubber tube in the vagina, to promote drainage. As 
 the discharge lessens and tenderness becomes less, the rubber tube 
 may be substituted by a gl\x-erin tampon, changed daily. When the 
 chronic stage is reached the infection probably will be found to be 
 localized in the cervix or the Fallopian tubes; the local treatment 
 of these affections is discussed below. 
 
 Chronic Gonococcic Vaginitis, especially' in children, is most success- 
 fully combated by the use of vaccines; without their use a leucor- 
 rheal discharge may persist indefinitely, and though no gonococci 
 may be found by microscopical examination on many occasions, any 
 local irritation may bring them from their hiding places. In both 
 children and adults a so-called "cure" of the disease usually means 
 only latency of symptoms. Some authorities teach that a woman 
 once infected with gonococci is always infected. 
 
ESDOMKTIilTlS 1()7;^ 
 
 Til till- use of \a('ciiK's for cliroiiif pmococcif \af;initis in cliildrcii, I 
 liavo followed the direetioiis of B. W. Ihimiltoii (IDIO): give r)(),()()(),()()() 
 killed gonoeocc'i by li\ pcHlerinic injection every fifth day, increasing 
 the dose by 10,( )()(),()()() until five injections have been given, the last 
 dose l)eing 9(),()()(),(HH) gonococci. After a ten-day interxal repeat the 
 same treatment if ne<'essary. In recent cases Hamilton found that 
 six injections usually cured. 
 
 Endocervicitis. — This usually is gonorrheal in origin, mixed infec- 
 tion occurring subsccjucntly and aggravating the condition. The 
 chief symptom is a leucorrheal discharge, thick and i)urulent. ]\Ien- 
 struation occurs irregularly, and usually the flow is greater than normal. 
 Examination through the speculum usually reveals a plug of tenacious 
 muco-pus protruding from the os. Microscopically, the glands which 
 line the cervical canal are seen to be swollen and cystic, and much 
 increase in the stroma may occur, leading to hypertrophy or elonga- 
 tion of the cervix. The cer\ix may ha\e erosions or actual ulcerations 
 on its \aginal surface. 
 
 Treatment. — Treatment by })alliative means (douches, tampons, 
 local aj)j)lications or argyrol, iodin, etc.) rarely is efficient. Even 
 thorough scraping of the cer\ical canal, the patient being anesthe- 
 tized, generally fails to efYect a cure. The best treatment is formal 
 excision of the diseased tissue, with plastic restoration of the cervical 
 canal: the cervix is split bilaterally, and a wedge of tissue (including 
 the cervical mucosa) is removed from each lip; then the cervical flaps 
 are folded upon themselves and their free borders sutured to the mucosa 
 at the mternal os {Schroeders operation, Figs. 1000 and 1001). 
 
 Fig. 1000. — Schroeder's operation: the Fig. 1001. — Schrocder's operation: the 
 
 shaded areas are excised. flaps are sutured. 
 
 Endometritis. — Endometritis is a much rarer affection than com- 
 monly believed. ]\Iost patients said to have endometritis have an 
 entirely different lesion as the main cause of their symptoms. The 
 symptoms of which they complain are painful, prolonged and irregular 
 menstruation, leucorrheal discharge between their periods, a certain 
 amount of backache, etc. Examination shows the existence of endo- 
 cervicitis, or salpingitis, or both; and it is some such lesion, and not 
 a possibly accompanying but relatively insignificant endometritis, 
 which is responsible for the symptoms. Endometritis which exists 
 as the most important lesion usually results from infection following 
 68 
 
1074 
 
 SURGERY OF THE FEMALE GENITALS 
 
 abortion, miscarriage, or labor. Occasionally the disease occurs in 
 the nullipara or in the aged; in these instances it usually is caused by 
 stenosis of the os, or displacements of the uterus which cause conges- 
 tion or interfere with proper drainage. If the disease continues long 
 untreated, the entire uterine body may become affected {metritis). 
 The diagnosis of endometritis, except in the rare virginal and senile 
 forms, depends upon the recognition of the symptoms mentioned above 
 occurring after a miscarriage or a prolonged convalescence from 
 labor. 
 
 Fig. 1002. — Curettage of the uterus. (Findley.) 
 
 Treatment. — Much can be done to prevent the de^'elopment of 
 endometritis by avoiding infection in the puerperium, but when the 
 disease is fully established, treatment is not very satisfactory. The 
 first essential is to secure free drainage, by dilatation of the os, main- 
 tained by introduction of a glass drainage tube (Wylie's drain); the 
 hypertrophied and diseased endometrium should be remo^^ed afthe 
 same time by curette (Fig. 1002), but this step is quite useless unless 
 free drainage is provided after the operation. The tube should be 
 retained for several weeks, and may be replaced later if necessary. If 
 other lesions (endocervicitis, salpingitis) exist they should receive 
 appropriate treatment. 
 
 Acute Metritis. — Acute metritis is seldom seen except in cases of 
 puerperal sepsis (p. 1092). 
 
SALPINGITIS 1075 
 
 Chronic Metritis.^Chronic metritis, as noted above, usually is a 
 se(iiifl of iu'<,^lc(tc(i cases of endometritis. At first the uterus is large, 
 soft an<l l)opgy, but later becomes sclerosed, though usually retaining 
 some enlargement. Hyaline degeneration is not infrequent, and malig- 
 nant changes may occur. The .symptoms resemble those of chronic 
 endometritis, but usually are more .severe and often are accompanied 
 by pseudo-hysterical phenomena. Menorrhagia is excessive, and the 
 patients become chronic invalids. The diagnosis from small intersti- 
 tial or submucous fibroids may be difficult. The only efficient trrat- 
 iiicnf is hysterectomy. The condition is no more curable by medicine 
 or ])alliativc local treatment than sclerosis of any other organ. 
 
 Salpingitis. — Infiammation of the Fallopian tubes usually is due 
 to the local action of gonococci, the infection travelling upward by 
 gradual steps from its resting places in the vulva and cervix. Tuber- 
 culosis of the Fallopian tubes has been mentioned in Chapter XXII. 
 
 Acute Salpingitis. — Acute salpingitis is most frequent in nulliparae; 
 it may occur during an acute attack of gonorrhea (vulvo-vaginitis and 
 urethritis) or may arise later as the result of some factor which lessens 
 the resistance of the pelvic organs. There is always a certain amount 
 of peri-salpingitis (pelvic peritonitis) accompanying acute inflammation 
 of the tubes, and pathologically the condition is not unlike an attack of 
 appendicitis, except that the infecting organism is the gonococcus and 
 not the more deadly streptococcus or colon bacillus. The symptoms 
 are those of peritonitis localized to the pelvic region, usually more 
 marked on one side than on the other, and not attended by notable 
 gastro-intestinal symptoms. The tenderness is close to Poupart's 
 ligament, too low and too near the median line for typical appendicitis; 
 and the history of the case and vaginal examination almost always 
 indicate the true condition. 
 
 Treatment. — Keep the patient in bed, and treat her as for diffuse 
 peritonitis (p. 811); there is no fear of gangrene or perforation of the 
 tube, as there is when the appendix is acutely inflamed; and the acute 
 attack subsides almost invariably within a few days. The exceptions 
 are a few cases of salpingitis of puerperal origin; but most of these, 
 even, subside under proper conservative treatment. The mortality 
 following early operation is high; but if recurrent attacks of pelvic 
 peritonitis occur in spite of conservative treatment it may become 
 necessary to operate before the chronic stage has been reached. The 
 operation consists in removal of the afTected tube (salpingectomy, 
 p. 1080) and of the ovary also if this is involved. But whenever 
 possible no operation should be done for several months after the 
 subsidence of an acute attack; after such an interval the virulence of 
 the microbes is very much attenuated, and often the pus in the tube 
 is found to be sterile. 
 
 Chronic Salpingitis. — Chronic salpingitis is a term used to describe 
 a condition which is not so much a chronic inflammation of the tubes, 
 as it is the result of a previous acute inflammation. The tubes and 
 ovaries are bound down in adhesions, often involving omentum, 
 
1076 SURGERY OF THE FEMALE GENITALS 
 
 sigmoid, cecum and appendix, and less often the pelvic coils of small 
 intestine. There is difficulty, and often pain, in securing evacuation 
 of the bowels; an aching sensation, or dragging pain, is nearly constant 
 in the lateral pelvic regions, especially when the patient is on her feet; 
 referred pains (small of back, thighs, groins) are frequently present; 
 there usually is leucorrhea, with painful, profuse, and irregular men- 
 struation, and the woman becomes a chronic invalid. Examination 
 shows the uterus and adnexa more or less fixed by adhesions; con- 
 siderable tenderness is present; and the pelvic organs cannot be 
 clearly outlined. 
 
 Treatment consists in removal of the focus or rather foci of infection 
 {salpingo-odphorcctojiu/), releasing the adhesions, and covering denuded 
 peritoneal surfaces by infolding or by omental grafts. The appendix 
 usuallv should be removed also. 
 
 Fig. 1003. — Right pyosalpinx, seen from posterior aspect. The tube is distended, 
 pouched, and surrounds the ovary. Episcopal Hospital. 
 
 Pyosalpinx, or Pus-tube, results from accumulation of the products 
 of inflammation within the lumen of the Fallopian tube, owing to 
 inflammatory occlusion of the fimbriated and uterine extremities 
 (Fig. 1003). The exciting cause almost always is the gonococcus, and 
 the condition usually is a remote sequel of acute salpingitis. It has 
 been noted already that gonococcic infection of the tubes becomes 
 attenuated soon, and that after several months the contents usually 
 are sterile. A patient with pus-tubes (both sides usually are diseased) 
 as a rule gives a history of having passed through several attacks of 
 pelvic peritonitis; and in many cases a distinct history of the primary 
 infection can be secured. A pus-tube often follows the first childbirth 
 in cases where the patient has been inoculated with not very virulent 
 gonococci; thereafter the woman usually is sterile. If the pus-tube 
 in such a woman first begins to cause symptoms a number of years 
 after the last childbirth, it may be mistaken for a case of ectopic 
 gestation (p. 1090). Frequently' pus-tubes exist for years without 
 causing notable symptoms; but in most cases there is an annoying 
 leucorrhea, and the patient may be completely disabled by painful 
 
pyOSALPI\'X AM) Tllil) OVAh'IAX AliSCESS 1077 
 
 iiilli«'si()iis to the intestinal tract, l)y recurrent attacks of jx-Kic peri- 
 tonitis from leakat,^' of the contents of the sac, etc. On examination 
 it is usual to Hnd the cervix disphiced, and a mass in the recto-uterine 
 pouch, sometimes ek'arly demonstral)k' as sjjriuf^ing from one side or 
 other of the uterus; a simihir hut smaller mass, not large enouf^h to 
 occup\ the i)ouch of Douglas, ma\' he present on the other side of the 
 uterus. l*us-tul)cs usually are fixed hy adhesions, hut the\' may he 
 very movahle. and their existence should not he ruled out on the 
 fjround of mohility alone. A low, immohile mass, esjx'ciaily if it 
 results from puerperal infection, almost always is a pelvic ahscess; 
 |)us-tul)cs form a hifjh, not a low mass. 
 
 Treatment. — If symptoms are present the diseased stru<tures 
 should he removed. If the woman is younjj: and the ovary healthy, 
 it should be left, only the tube being remox'cd, but in man\' cases 
 the ovary is degenerated ("cystic degeneration" from chronic ooi)h(>r- 
 itis, p. 1078) and will ])rove useless or even harmful if i)reserved. The 
 entire tube should be removed, excising its interstitial part from the 
 uterine cornu; in some cases, in addition to the removal of both tubes 
 and ovaries it is necessary to remove the uterus also, either to facili- 
 tate the operation, or because this organ itself is diseased (chronic 
 metritis). The operation of salpingo-oophorectomy is described at 
 p. 1079. If the woman complains of no particular symptoms, it often 
 is best to do no operation. I have known a woman with an undeniable 
 pus-tube pass through a normal pregnancy and puerperium and give 
 birth to a healthy child. 
 
 Rupture of a pus-tube is rare while its contents are still highly infec- 
 tious; when it occurs, it is followed by diffuse peritonitis, which is best 
 treated not by immediate operation, but by strict adherence to the 
 rules laid down in Chapter XXII for the non-operative treatment of 
 diffuse peritonitis. Immediate operation has a very high mortality, 
 but if the patient is treated expectantly the infection almost always 
 becomes localized again, frequently in the form of a pelvic abscess. 
 
 Tubo-ovarian Abscesses. — This is an abscess which involves both 
 tube and ovary (Fig. 1004). Usually the primary condition is that of 
 pyosalpiiLX, and the ovary becomes invaded by direct extension. It 
 is rare for an o\arian abscess to exist alone, or for it to spread to the 
 tube secondarily. But when a small ovarian cyst or corpus luteum 
 bursts into an adherent pus-tube, infection of the whole ovary ma}' 
 result, the tube and ovary then forming one mass. Sometimes tube 
 and ovary are in communication only through an intervening pelvic 
 abscess. It is difficult to distinguish a tubo-ovarian abscess from an 
 ordinary pus-tube before operation, as the symptoms and physical 
 signs are almost identical. 
 
 Treatment is the same as for pyosalpinx. 
 
 Hydrosalpinx. — Hydrosalpinx, or a collection of serous fluid in the 
 tube, sometimes develops as a terminal stage of pyosalpinx; often, 
 however, the collection of fluid appears to have been serous from the 
 beginning. Hydrosalpinx frequently develops on one or both sides 
 
1078 
 
 SURGERY OF THE FEMALE GENITALS 
 
 in cases of uterine fibroids. Treatment is tliat of the complicating 
 condition. 
 
 Fi(i. 1UU4. — Left tubo-ovarian abscess, seen from posterior aspect. Ruptured Ijefore 
 operation, causing fatal peritonitis (colon bacillus). Epi.scopal Ho.spital. 
 
 Oophoritis or Ovaritis is much less frequent antl produces much 
 less conspicuous symptoms than salpingitis. Like the latter condition, 
 of which it is almost always a direct sequel, it may be acute or chronic. 
 The symptoms cannot well be differentiated from those of the compli- 
 cating salpingitis. In acute ovaritis the ovary is swollen, tender, and 
 often prolapsed into Douglas's pouch; abscess of the ovary is rare unless 
 it is the result of secondary infection of a preexistent ovarian cyst, or 
 occurs in the form of a tubo-ovarian abscess, already described. 
 
 
 ^_^_^J.s<-~-»^-. ' 
 
 ^n 
 
 B^ 
 
 Jtu. 
 
 }- 
 
 
 ^•'^IHlr 
 
 ^^S^^w^S^'^ 
 
 Kf^'^K 
 
 y 
 
 
 R^MH^v 
 
 s^^HHIflll 
 
 ^jgttj^yk.j^ 
 
 4 
 
 
 W^" 
 
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 ^ 
 
 Fig. 1005. — Microcystic degeneration of the ovary; the ovary to the right shows 
 numerous small cysts scattered over the surface; these are Graafian follicles which 
 have undergone cystic degeneration, and which it is said may take on excessive growth 
 and develop into large tumors, or may remain as here represented ; on the other side 
 is shown a similar condition of the ovary in section. (Dudley.) 
 
 Treatment. — In acute ovaritis the treatment should be the same as in 
 cases of acute salpingitis. If suppuration occurs, the proper treat- 
 ment is oophorectomy. In chronic ovaritis the ovary is the seat of 
 "cystic degeneration," and should be removed along with the tube 
 if this is diseased (Fig. 1005); since both ovaries usually are affected. 
 
SALPINanooi'IIOUKCTOMy 
 
 1070 
 
 it is well, if the patient is a youni;; woinaii, uiul a portion of the ovary 
 remains healthy, to leave it as a transphmt in the abdominal wound; 
 there are fair prospeets that it will possess sufficient function to 
 j)re\cnt ;in artificiid nK'no]);nise. 
 
 Salpingo-oophorectomy. The abdomen is opened l)y a paraniccHan 
 incision about tiiree or four inches long, above the pubes. In any 
 case in which there is any possibiUty of pus being present, the surgeon 
 should wall off the small intestines with gauze packs as soon as the 
 l)eritoneuni is opened, and before the i)ehis is explored. Place the first 
 gauze i)ack on the right or left side of the pelvic cavity, not in the 
 
 Fig. 1006. — Isolating the pelvic cavity bv the use of gauze packs. 
 
 (Dudley.) 
 
 (See Fig. 812.) 
 
 mid-line; if the first pack is inserted in the mid-line the intestines will 
 prolapse into the pelvis on both sides of it, and it will be more difficult 
 to control them. The second gauze pack is placed in the mid-line, 
 and the third on the left, thus pushing the troublesome small intestines 
 completely out of harm's way (Fig. lOOG). If it is known to be a clean 
 case it will facilitate these manoeuvres to place the patient in the Tren- 
 delenburg (high pelvic) position as soon as the abdomen has been 
 opened; but if there is any danger of infection, it is safer to isolate 
 the general peritoneal cavity by gauze while the patient's body is 
 still horizontal, and then to raise it into the Trendelenburg position. 
 
1080 
 
 SURGERY OF THE FEMALE GENITALS 
 
 If many adhesions are present it may be difficult at first to recog- 
 nize anatomical landmarks. First locate the fundus of the uterus. 
 Sometimes it is covered by omentum or sigmoid. Then cautiously 
 and gently work your fingers down behind it until Douglas's cul-de-sac 
 is reached. Then endeavor to isolate the tubes and ovaries by blunt 
 dissection with the fingers, working from the mid-line outward and 
 pushing the omentum and intestine away from the pelvic organs 
 rather than enucleating the latter from the intestines. It is not very 
 difficult to tear a hole in the intestines if undue haste or force is em- 
 ployed. From time to time mop up the clotted blood which collects 
 in the pelvis as the result of rupture of adhesions. When at last the 
 posterior surfaces of the broad ligaments are outlined, turn your atten- 
 tion to their anterior surfaces, beginning at the fundus of the uterus 
 again, where the attachments of the tube and of the roimd ligament 
 form ^•aluable landmarks, and then work out toward the sides of 
 the pehis. 
 
 Fig. 1007. — Salpingo-oophorectomy: on the right the suturing has been completed; 
 on the left the method of resecting the uterine cornu is indicated. (Dudley.) 
 
 If few or no adhesions are present, the tube and o^'ary from each 
 side can be brought into the wound without difficulty. If the tube 
 only is diseased, it alone should be removed (salpingectomy); or if 
 the tube is healthy and the ovary diseased, oophorectomy should be 
 done. In most cases both tube and ovary are removed together. 
 The blood supply is readily controlled by a ligature around the ovarian 
 artery, at the lateral margin of the broad ligament, and another close 
 
liUiTII IXJCRIE^ 1081 
 
 to tli(> iitcriis, just I)(>l()\v llu; tiihc, wIktc tlic uterine and oxariaii 
 arteries aiiastoniose. 'I'lie tube and <>\ary are tiien cut free Iroiu the 
 broad ligament and any ooziuj^ jjoiiits toini)()rarily claniped in hemo- 
 stats. The tube should be removed by reseetiuj^ a wedjie-shajx'd i)iece 
 of the uterine eormi, unless the uterine tissue is ver\' friable, and will 
 not hold sutures, when it is sufficient to li<;ate the uteriix' stump of 
 the tube. The eut edges of the broad ligament are then sutured by a 
 loek stitch of chromic catgut, controlling any venous oozing (Fig. 
 1007). The ends of the ligatures on the ovarian, and uterine arteries 
 are then tied together, tlnis sliorteniiig tlie l)road ligament, and retain- 
 ing the fundus in proper position. I'sually it is well to invert the edges 
 of the broad ligament by another row of sero-serous sutures, burying 
 the first row and covering the uterine stump of the tube. This lessens 
 the chance of post-()])erative adhesions. 
 
 In some cases it is safer to leave a tube or gauze to drain the floor 
 of the pelvis, but where there has not been much soiling of the pelvic 
 structures, and no oozing i)ersists, the abdonunal wound may be 
 closed without drainage. 
 
 Birth Injuries. — Lacerations of the cervix and perineum are the 
 most frc(|uent obstetrical injuries, and often produce sucii distressing 
 s\mpt()ms as to demand operative relief. 
 
 Lacerations of the Cervix may be unilateral or bilateral; anterior or 
 posterior lacerations are rare, as are stellate lacerations. When these 
 patients reach the surgeon healing has occurred, but it is healing w^ith 
 deformity: the cervical mucosa becomes everted, and resembles an 
 ulcerated surface; erosions frequently form on the vaginal portion of 
 the cervix, and annoying leucorrhea frequently is present. If the 
 lacerations are very wide and deep, subsequent pregnancies may ter- 
 minate in miscarriages from very slight provocation, or conception 
 may not occur at all. Moreover, carcinoma of the cervix seldom 
 occurs except in the scar of an old laceration; and this is the chief 
 argument in favor of habitual operative treatment. But before any 
 operation is done for laceration of the cervix, it is important to remedy 
 inflammatory conditions in the uterus and adnexa, since the inter- 
 ference with free drainage which may result from repair of a cervical 
 tear may cause retention of uterine secretions, thus aggravating a 
 chronic endometritis and perhaps indirectly leading to the develop- 
 ment of salpingitis. At the time of operation the uterine cavity 
 should be cleansed by the curette, and immediately after repair 
 of the cervix the tubal lesion, if any exists, should be treated by 
 laparotomy. 
 
 Treatment. — The operation for the repair of a lacerated cervix is 
 known as trachelorrhaphy {''tracJielopIasty," Emmett, 1809). It con- 
 sists in denuding the torn surfaces, excising the cicatricial tissue, and 
 restoring the cervix to normal shape by sutures. The technique is 
 sufficiently indicated in the accompanying illustration (Fig. 1008). In 
 some cases where the lacerations are very extensive, or the cervix 
 
1082 
 
 SURGERY OF THE FEMALE GENITALS 
 
 hypertrophied, amputation of the cervix is required. Schroeder's 
 method has already been ilhistrated (p. lOT))), 
 
 Lacerations of the Perineum and Pelvic Floor usually produce more 
 discomfort than lacerations of the cervix. The levator ani muscles 
 are composed typically of three portions: a posterior portion, entirely 
 
 beneath the rectum, which is 
 not of importance in the pres- 
 ent connection; a middle por- 
 tion, which is closely applied 
 to the sides of the rectum; 
 and an anterior portion, 
 which meets with the corre- 
 sponding fibers from the op- 
 posite side, at the perineal 
 centre. In superficial tears 
 little more is torn than the 
 juncture of these anterior 
 fibers, and some of the fibres 
 of the transversus perinei, at 
 the perineal centre. In com- 
 plete tears the rupture extends 
 down through the perineal 
 centre and involves the 
 sphincter ani, almost always 
 entailing fecal incontinence. 
 Neither a superficial nor a 
 complete tear of the perineum 
 necessarily involves the pelvic 
 floor proper, so there is not 
 much loss of support to the 
 pelvic organs; it is onl}' when 
 the tear extends up one or 
 both lateral sulci of the 
 vagina, rupturing the middle fibres of the levator ani and detaching 
 them from the sides of the rectum that there develops a tendency 
 to hernia of the pelvic contents through the vulvar orifice. 
 
 The symptoms due to this loss of support in the pelvic floor are 
 chiefly a feeling of weakness in the pelvis when the patient stands or 
 walks; and dragging sensations in the lower abdomen, with pains 
 referred oftenest to the ovarian or lumbar regions. In typical cases 
 the vulvar orifice gapes, the anus falls backward toward the coccyx, 
 and descends to a lower plane, no longer being placed in a well marked 
 cleft between the nates. In many cases the anterior wall of the rectum 
 protrudes beneath the posterior vaginal wall, forming a rectocele (Fig. 
 1009); and in connection with this there often develops an anterior 
 colpocele or a cystocele (p. 1088). If the condition is neglected it fre- 
 quently leads to prolapse or to procidentia of the nterus. 
 
 Fig. 1008.— Trachelorrhaphy: after excision 
 of the cicatricial tissue, sutures of No. 2 chromic 
 catgut are passed, beginning at the apex. 
 (Findley.) 
 
I'ERIXEOinniAI'HY 
 
 1083 
 
 Trtatincnt. — TIic operation for the repair of a lacerated perineum 
 is known as perineorrhaphy." Its nature and extent depend on the 
 character of tlie tear. If Uoth lateral sulci of the va(jina are involved, 
 tlic best operation is of the tyi)e devised hy Kmmett (188.'i): this 
 consists in denudinj^: the rehaxed areas, reunitinji; tlie levatores ani 
 muscles to the lateral rectal and posterior va|;;inal walls, and restoring 
 the external perineum hy transverse sutures, known as "crown 
 sutures." The manner in which the denudation is accomplished is of 
 little moment; many surgeons follow Emmett in employing scissors. 
 Personally. I prefer the scalpel, and I am in the hal)it of proceeding 
 
 as Follows: 
 
 Fig. 1009. — Rectocele and cystocele. Pennsylvania Hospital. 
 
 1. Denudation. — A tenaculum is placed at the lowest myrtiform 
 caruncle on each side, and these points are well retracted exposing 
 the rectocele. A point on this is selected, which when draW'U forward 
 by tenaculum will reach almost but not quite to the urinary meatus 
 (Fig. 1010). When these three tenacula are placed in apposition the 
 normal form of the vulvar opening is restored. A fourth tenaculum 
 is then placed in the mid-line at the mucocutaneous juncture. Point 
 h (Fig. 1010) is then drawn upward and point /downward, making the 
 line 6/ taut. The vaginal mucosa is incised from b to/, and the muco- 
 cutaneous border from / to e and from f to d. The flap b f e is then 
 dissected up with scalpel until c, the apex of the lateral vaginal sulcus, 
 is reached; this point becomes apparent when the points b and e are 
 drawn widely apart, forming the lines b c and e c (Fig. 1011). When 
 
 1 It was Parvin's teaching that the terms Irnchelorrhaphy and perineorrhaphy 
 should be hmited to immediate repair of birth injuries; and that the operations 
 when done at later periods should be called Iracheloplasty and perineoplasty. The 
 usual opei'ation for repair of a lacerated perineum involves also the vagina, whence 
 the term posterior colporrhaphy or colpo-perineorrhaphy. 
 
1084 
 
 SURGERY OF THE FEMALE GENITALS 
 
 Fig. 1010. — Typical incomplete lacer- 
 ation of the perineum. The tenaculum 
 hooked into the crest of the rectoccle at 
 point b draws it slightly forward. The 
 other two tenacula are hooked into the 
 lowest remains of the hymen, points d 
 and e (carunculce myrtiformes) . The three 
 tenacula if apjiroximated would brinti into 
 coincidence points h, d, and e, and would 
 show what surfaces should be united. 
 (Dudley.) 
 
 Fig. 1012. — This shows the surfaces 
 denuded and ready for suturing. Some 
 operators prefer to expose the surface 
 on both sides for denudation in the 
 manner in which they are exposed in this 
 illustration. In the use of either method 
 it is desirable to denude on each side 
 somewhat further back into the sulcus 
 than is here shown. (Dudley.) 
 
 Fig. 1011.— Same as 1010. Tenacu- 
 lum at d removed and placed at /. 
 Tenacula b, e, and / make traction so 
 as to render tense, lift up and expose 
 for denudation the torn sulcus of the 
 left side. The ridges formed by the 
 structures drawn taut indicate the out- 
 line of the surface to be denuded. 
 (Dudley.) 
 
 the dissection has been carried as 
 high as these Unes, the flap of 
 mucous membrane is cut free by 
 dividing it along e c and h c with 
 straight scissors. The same pro- 
 cedure is then carried out on the 
 patient's right side, until the lines 
 d a and b a are reached, when the 
 flap is cut free by scissors passed 
 along these lines. The denuded 
 surfaces now have the appearance 
 represented in Fig. 1012. 
 
 2. Suture. — The method of in- 
 serting the sutures is important: 
 in a typical Emmett operation the 
 lateral vaginal sulci are sutured 
 first, beginning at the apex of the 
 denuded area and working toward 
 the vaginal outlet (Fig. 1013). 
 Finally the crown sutures, usually 
 of silkworm gut, are passed from 
 the skin surface deeply into the 
 tissues of the perineum from one 
 side to the other, uniting the 
 
PERINEOliRIIM'IIY 
 
 1085 
 
 k'vatores aiii in the iiKMlian line. Dudley modifies this method l)y 
 makiiifj: separate suture of the levatores ani with huried sutures and 
 then elosini,' the vaginal sulei (Fig. 1011). Finally the skin of the 
 perineum is closed. 
 
 Fk7. 1013. — Perineorrhaphy: method of i)assing sutures in one of the hiteral sulci. 
 
 In cases where the chief damage is at the vulvar outlet, it is sufficient 
 to suture the levatores ani alone. They are easily exposed through 
 an incision about two or three 
 inches in length along the muco- 
 cutaneous border, from the 
 lowest myrtiform caruncle on 
 one side to that on the other. 
 The vaginal mucous membrane 
 is then raised by blunt dissec- 
 tion, the le^•ator ani on each 
 side is identified and drawn 
 into the wound with forceps, 
 and is united to its fellow of 
 the opposite side by buried 
 mattress sutures of chromic 
 gut. The skin incision is then 
 closed. 
 
 In cases of complete laceration 
 of the perineum, it is necessary, 
 in addition to the other oper- 
 ative procedures indicated, also 
 to reunite the retracted ends 
 of the ruptured sphincter ani; 
 these should be exposed through 
 a transverse or inverted V- 
 shaped incision in front of the 
 anus, should be accurately iden- 
 tified, and sutured to each other by buried sutures. The retracted 
 ends of the ruptured sphincter produce dimples in the skin of the 
 anus, and the skin between the retracted ends is not puckered as is 
 the rest of the skin surrounding the anus. When these retracted 
 
 Fig. 1014. — All the sutures in the two 
 lateral sulci have been introduced and 
 tied. The levatores ani have been united 
 in the median line by buried sutures. 
 The crown suture, which brings together 
 the two carunculie niyrtiformes and the 
 posterior vaginal wall, is being tied. 
 This completes the intravaginal part of 
 the operation. (Dudlej'.) 
 
1086 SURGERY OF THE FEMALE GENITALS 
 
 ends have been sutured to each other the skin is puckered normally 
 around the whole circumference of the anus. 
 
 Displacements of the Uterus. — Anterior Displacement. — Anteflexion, 
 involving a bend in the axis of the uterine canal, frequently accom- 
 panies stenosis of the cervix, and requires the same treatment (p. 1070). 
 In anteversion, which is rarer than anteflexion, the cervix is displaced 
 backward, there being no abnormal bend in the axis of the uterine 
 canal. Usually the displacement is caused by, or at least is asso- 
 ciated with, pelvic inflammatory disease, and is relieved by proper 
 treatment of the complicating condition. 
 
 Posterior Displacement is common; and here also retroflexion is more 
 usual than retroversion. In extreme degrees the fundus occupies the 
 pouch of Douglas. If the displacement follows pelvic inflammatory 
 disease the uterus may be fixed in its malposition by adhesions, and 
 may cause much discomfort. In cases due to relaxation of the pelvic 
 floor, following pregnancy, no noteworthy symptoms may be caused 
 unless relaxation is so extreme as to permit prolapse of the uterus, 
 with its complicating lesions. 
 
 Treatment. — In many cases following pregnancy {subinvolution of the 
 uterus), unattended by complicating lesions, and causing no severe 
 symptoms, permanent restoration of the uterus to its normal position 
 may be secured by mechanical treatment. The fundus should be 
 replaced manually by the surgeon several times weekly, and its reten- 
 tion in normal position favored by inserting a tampon behind the 
 cervix after the fundus has been brought forward. Sometimes a 
 pessary is employed for this purpose. The woman should do no heavy 
 lifting or arduous work for months; should keep her bowels freely 
 opened, avoiding constipation and its attendant straining in defeca- 
 tion; and should wear no tight clothing which causes downward 
 pressure on the pelvic organs. If the uterus is subinvoluted, it is 
 well for the patient to spend much time in bed at first. She should 
 lie flat on the abdomen or in the Sims posture for several hours each 
 day, and may assume with advantage the knee-chest posture for ten 
 or fifteen minutes several times daily. In most cases no operative 
 treatment is required, unless demanded by complicating lesions. 
 Innumerable operations have been devised to hold the uterus forward 
 (hysteropexy) . Shortening of the round ligaments in the inguinal canal 
 (Alexander, 1882) presents the disadvantage that it does not permit 
 treatment of accompanying pelvic lesions; there are exceedingly few 
 cases in which it is indicated. Intraperitoneal shortening of the round 
 ligainents is preferable. The operation may be done as follows: A 
 forceps is thrust through the broad ligament from its posterior 
 surface, just beneath the tube and close to the uterus. This forceps 
 then grasps the round ligament about two inches from its uterine 
 end, and draws it through the broad ligament (Fig. 1015). The 
 other round ligament is treated similarly, and then the two round 
 ligaments are sutured to each other and to the posterior wall of the 
 uterus just back of the fundus (Webster, 1901 ; Baldy, 1903). If they 
 
I'h'OLM'SK OF rill': UTERUS 
 
 1087 
 
 arc sutured too low on the uterus tliey will i)ull the (rr\ix forward 
 and increase the retro-displacement of the fundus. J'ciitro-.svspni.mm 
 of the iifrnis consists in suturin<^ the fundus to the anterior ahdominal 
 wall, with ahsorhahle sutures; if non-ahsorhahle sutures are used, the 
 operation is known as Ventro-fixation. The operation should not be 
 done in any patient who has not reached the menopause. It is very 
 seldom indicated except as an incident in the operative treatment of 
 fjenital prolai)se in the female. 
 
 Fig. 1015. — Hysteropexy: both round ligaments have been jjulled through the broad 
 ligaments, and are about to be sutured to each other and to the fundus of the uterus. 
 (Baldy.) 
 
 Downward Displacement.^Usually this is a sequel of retrodisplace- 
 ment. When the axis of the uterus is changed so that it corresponds 
 with that of the vagina, descent is almost invariably the sequel. It 
 is predisposed to by loss of support, the result of lacerations of the 
 pelvic floor and perineum, or of the atrophy which sets in about the 
 time of the menopause; and by increased pressure from above, such 
 as tumors of the uterus or abdominal organs, obesity, tight lacing, 
 straining in defecation, etc. Several degrees of descent of the uterus 
 
1088 
 
 SURGERY OF THE FEMALE CEXITALS 
 
 are recognized: in prolapse the uterus still remains in the vaginal 
 canal, usually pushing before it a cystocele or rectocele (Fig. lOlGj; 
 while in procidentia the uterus protrudes from the vulva (Fig, 1017). 
 The cervix becomes hypertrophied from passive congestion and fric- 
 tion, and frequently is ulcerated. The anterior vaginal wall is pushed 
 or pulled down by the prolapsing uterus, and anterior colpocele, or even 
 cystocele (prolapse of the bladder through the anterior vaginal wall) 
 results. Residual urine collects in the bladder pouch, and digital 
 pressure may be necessary to secure evacuation of urine. The occur- 
 rence of posterior colpocele and rectocele has been discussed at p. 10S3. 
 
 Fig. 1016. — Prolapse of the uterus; 
 large rectocele; also hemorrhoids. 
 Pennsylvania Hospital. 
 
 Fig. 1017. — Procidentia uteri and ulcer- 
 ation of the cer\-ix. Patient, aged thirty- 
 six j-ears, has had eight children, including 
 one set of twins. Pennsylvania Hospital. 
 
 Treatment involves (1) repair of the anterior vaginal wall; (2) 
 repair of the pelvic floor and .perineum; and frequently also (3) some 
 intra-abdominal operation to secure the uterus in a position of ante- 
 version, thus restoring the normal relation of the axis of the uterus 
 to that of the vagina; (4) if the cervix is very large it should be 
 amputated as the first step of the operation (p. 1073). 
 
 Repair of the anterior vaginal wall may be done by making a median 
 incision from just back of the urinary meatus to a point about an inch 
 in front of the cervix; here the incision diverges in two branches, so 
 as to form an inverted Y. This incision is carried through the mucosa 
 exposing the muscular wall of the bladder. The mucous flaps are then 
 reflected laterally by gauze dissection, until the operator's finger 
 can detect the margins of the rent in the vesico-vaginal fascia through 
 which the hernia of the bladder has occurred. These fascial margins 
 are then sutured together in the mid-line by l:)uried mattress sutures 
 of chromic gut, taking care not to penetrate the bladder. If no such 
 margins can be detected, the sutures should at any rate be passed as 
 far laterally as possible, through the outer layers of the vesical wall, 
 
GEMTAL I'lSTVL^ 
 
 1089 
 
 infolding this upon itself aiul thus overcoming the prolapse of tlie 
 bladder. The flaps of vaginal mucosa are now to be sutured; if 
 redundant the excess may be excised. 
 
 The operation for the repair of a cystocele never is efficient unless 
 supplemented hij repair of the pelvic floor and perineum, as already 
 described (p. 1083). 
 
 In cases where the uterus is diseased and has to be removed, great 
 care sliould be taken to implant the stumps of the broad and round 
 Hgaments into the remains of the cervix or the vaginal vault, to prevent 
 prolapse. In severe or recurrent cases the cervical stump may be 
 implanted in the abdominal wall. 
 
 Genital Fistulae. — Most cases of genital fistul* in the female result 
 from se])aration of sloughs which have been produced by i)rolonged 
 or excessive pressure during partu- 
 rition. They are rare at the jiresent 
 day, owing chiefly to the advances 
 in obstetrics. Some occur as the 
 result of careless operating (Fig. 
 1018), and others from ulceration 
 due to inflammation or malignant 
 disease. All except the latter usu- 
 ally may be cured by operative 
 treatment. By far the commonest 
 form of fistula is the vesicovaginal; 
 other fistulse (vesico-uterine, recto- 
 vaginal, recto-uterine, uretero-cervical, 
 etc.) are comparatively very rare. 
 The diagnosis depends on the recog- 
 nition of the leakage of urine or 
 fecal matter (or even merely flatus) 
 into the genital tract. Injection of 
 the bladder or rectum with colored 
 fluids (milk, methylene blue, etc.) 
 renders this fact certain. In most 
 cases the fistula can be brought to view by use of a speculum. 
 Uterine fistulse, however, cannot be thus exposed. 
 
 Treatment. — Preparator\- treatment before operation is of the 
 utmost importance. The phosphatic deposit of urinary salts around 
 the margins of the fistula must be removed gently, and their reforma- 
 tion prevented by rendering the urine acid. The patient must drink 
 plenty of water; copious hot vaginal douches should be given to cleanse 
 the parts, and the dermatitis of the vulva and adjacent skin should 
 also be relieved by appropriate remedies. After operation the patient 
 remains in bed about three weeks, and for the first two weeks constant 
 vesical drainage is assured by the use of an inlying catheter (prefer- 
 ably glass, with appropriate curve), which must be changed frequently. 
 
 1. When the fistulous tract can be exposed from below, it is usually 
 
 possible to close it by a plastic operation. The edges of the fistula 
 
 69 
 
 Fig. 1018. — Recto-vaginal (recto- 
 vestibular) fistula following attempted 
 repair of a laceration of the perineum. 
 Pennsylvania Hospital. 
 
1090 SURGERY OF THE FEMALE GENITALS 
 
 are pared obliquely, at the expense of its vaginal surface, and in an 
 oval form (Fig. 1019). The flap-splitting method seldom is required. 
 2. When the fistulous tract cannot he exposed frorn below, as is usually 
 the case in fistula? which involve the uterus, laparotomy becomes 
 necessary. The bladder is carefully separated from the uterus, and 
 the opening in each repaired separately. Hysterectomy may render 
 the operation easier or the cure more certain. 
 
 Fig. 1019. — Vesico-vaginal fistula, showing the proper area of denudation. Left 
 lateroprone position; exposure by Sims' speculum. (Dudley.) 
 
 Extra-uterine Pregnancy. — Ectopic gestation usually occurs in the 
 tube, and in most cases rupture of the tube occurs, or the embryo 
 is discharged into the peritoneal cavity through the fimbriated ex- 
 tremity of the tube {tubal abortion), from the sixth week to the third 
 month pregnancy. Occasionally rupture occurs into the cellular 
 tissue of the broad ligament; this is least unusual when pregnancy 
 occurs in the tube close to the uterine wall {ampullar pregnancy), 
 or as an interstitial pregnancy in that portion of the tube within the 
 uterine wall. In the latter case an intra-uterine abortion may occur. 
 After rupture or tubal abortion the embryo usually dies, but in rare 
 
EXTRA-UTERINE r REG NANCY 
 
 1091 
 
 cases it continues to grow (secondary abdominal i)regnancy) almost 
 
 to full term. 
 
 The causes of extra-uterine pregnanc\- are obscure. It occurs 
 oftenest in women who have been sterile for five years or more, and 
 is thought to be predisposed to by previous attacks of salpmgitis, 
 or congenital peculiarities of the tube (long and tortuous, with small 
 lumen or with diverticula). 
 
 Pm iO'?U —Ruptured tubal pregnancy; an eight weeks' fetus. Age twenty-three 
 vears 'one childbirth, four vears ago; had missed one period, and had had prenionitory 
 svmptoms for three days. Admitted to hospital with diagnosis of peritonitis; pulse. 
 150- temperature, 98° F.; leukocytes, 45,000; polynuclears, 94 per cent.; hemoglobin. 
 35 per cent. Correct diagnosis based on anemia. Operation fifteen hours after rupture. 
 Rccoverj-. Episcopal Hospital. 
 
 Symptoms and Diagnosis.— The usual early symptoms of normal 
 pregnancy may or may not be present; these include particularly, 
 morning sickness, increase in size of breasts, perhaps with pigmenta- 
 tion. In almost all cases there is a disturbance of the normal menstrual 
 periodicitv: often one period is missed and this is followed in a week 
 or so by irregular and scanty bleeding. Painful cramps may or may 
 not occur in the uterus. If vaginal examination is made, the presence 
 of a mass in the tube usually can be determined. It may be difficult 
 to distinguish this from a pyosalpinx, but in the latter there should 
 be no concomitant symptoms or signs of pregnancy. In ectopic 
 gestation the uterus usually is somewhat enlarged and the cervix is 
 softened. In the vast majority of cases the patient does not come 
 under the care of a physician until rupture of the tube occurs. This 
 is attended by agonizing pain, frequently so severe as to cause faint- 
 ness, and is followed by more or less profuse internal hemorrhage 
 evidenced by the usuaf signs. Indeed, symptoms of severe internal 
 
1092 SURGERY OF THE FEMALE GENITALS 
 
 hemorrhage in a woman previously in good health almost always 
 are clue to the rupture of an ectopic gestation sac. In a minority of 
 cases the bleeding occurs so slowly that no very acute symptoms are 
 produced, and the blood collects in the pelvis in the form of a pelvic 
 hematocele.^ 
 
 Treatment. — If the condition is recognized before rupture or tubal 
 abortion occurs, the affected tube should be removed at once. Exactly 
 the same treatment is required when rupture has occurred. Some 
 authorities, notably Simpson of Pittsburgh, contend that the hemor- 
 rhage always will cease of itself, and that no operation should be done 
 until the symptoms indicate that this has taken place. The majority 
 of surgeons and gynecologists, howe\'er, still believe that less risk is 
 run by immediate operation, even in the presence of profound shock 
 from hemorrhage, than by delay. Very little anesthetic is required. 
 The abdomen is rapidly opened above the pubes, the hand is intro- 
 duced and feels for the uterine appendages; usually there are no 
 adhesions, and it is very easy to tell by the sense of touch which is 
 the affected tube, even if this has not been ascertained before opening 
 the abdomen. The ruptured tube is brought into the wound and the 
 bleeding temporarily checked by the fingers. The diseased tube, 
 usually with its corresponding ovary, is then removed; the clotted 
 and semi-fluid blood is removed by forceps and gentle sponging, 
 but no irrigation is employed. It is well to pass the hand into each 
 kidney pouch and evacuate the clots which have accumulated there. 
 If the operation is done soon after rupture, and if most of the effused 
 blood and clot can be removed, the wound may be closed without 
 drainage. In late cases, especially if there is any suspicion of secondary 
 infection of the clot from the adjacent intestinal tract (not very rare) 
 it is safer to drain the pelvis for a few days. Bilateral tubal pregnancy 
 may occur, and it is always desirable to examine both tubes before 
 closing the abdomen. 
 
 Puerperal Sepsis. — Many cases of septic infection develop from 
 the genital tract during parturition and the puerperium. This is 
 owing chiefly to the ignorance and carelessness of midwives or incom- 
 petent general practitioners; but sometimes it is unavoidable, being 
 due solely to a preexistent infection, or to self-induced abortion. 
 The prevention of such infection is in the realm of obstetrics; but its 
 treatment frequently falls to the lot of the general surgeon, and it 
 behooves him to be prepared to do the best that is known for these 
 unfortunate patients. 
 
 The infection usually takes its origin at the placental site or in the 
 lacerated cervix; occasionally from lacerations in the vagina or at 
 the vulvar orifice. If fetal products are retained, and become infected 
 by putrefacti^'e microorganisms, sapremia develops (p. 75). This 
 
 1 Rupture of a rctcniion cyst of the ovary occasional!}' is followed b}^ severe internal 
 hemon'hage which may be indistinguishable from that due to ruptured tubal gesta- 
 tion (p. 1097). I have encountered two such cases. The treatment is the same 
 as for ruptured extra-uterine pregnancy. 
 
PVEIiVERAL SEPSIS HlOH 
 
 is coninioiier than invasion hy jjathofjenio bacteria, resulting in sep- 
 ilroniit: the latter may arise as a seeoiuhiry cdndition in a case of 
 sapreniia, hut more often is a ])riniary condition. Finally, if septic 
 thronibosi occurs, witli the hMJgenient of secondary emboli, the con- 
 dition is described as puerperal pyemia. 
 
 Retained Secundines. — It may hapjx'n after labor (i)articularly 
 in cases of mis(arria<j;e or abortion) that some of tlie fetal tissues are 
 retained. The question arises whether their expulsion shall be left 
 to nature, or whether they shall be removed by a surgeon. While 
 there is no doubt that in a great many such cases the unaided power 
 of nature is sufficient, yet I think surgical intervention hastens con- 
 valescence, and is to be recommended provided it is certain that 
 secundines have been retained for several days. If this fact is uncer- 
 tain, as it is in a great many cases, it is better to wait several days 
 longer and to evacuate the uterus surgically only when evidences of 
 sapremia become manifest. 
 
 Sapremia. — Local changes are confined mostly to the endometrium 
 {putrid endometritis) which is covered with brownish-gray pulpy 
 sloughs, with exceedmgly foul odor. Sapremia occurs oftenest after 
 full term labors or miscarriages near term. Symptoms usually do 
 not appear until the fourth day or later, and consist essentially in 
 elevation of temperature (perhaps as high as 105°) and other phe- 
 nomena of fever, with foul smelling discharge from the cervix. 
 
 Treatment. — As soon as such symptoms manifest themselves, the 
 uterus should be completely evacuated.^ This is best done by the 
 gloved finger, covered with gauze, or with the placental forceps, if 
 the cervix will not admit the finger easily. If a curette is used, it 
 should be the dull curette, but even a dull curette is dangerous under 
 such circumstances. It is very easy to perforate the puerperal uterus, 
 especially if diseased. The surgeon should adopt some system in 
 cleaning out the uterus, and should make sure that no large mass of 
 decomposing tissue is left behind. On several occasions I have been 
 forcetl to repeat the operation for persistence of symptoms, removing 
 large masses of foul smelling necrotic placenta which had been over- 
 looked by the previous operator. If bleeding is free, the uterine cavity 
 shoukl be packed with iodoform gauze, which is left in place for two 
 days; and a full dose of ergot should be administered. If no note- 
 worthy bleeding occurs, a gauze wick may be left within the cervix, 
 or if this tends to contract too much to permit free drainage, a rubber 
 tube should be passed through the cervix into the uterine cavity. 
 
 After prompt evacuation of such a uterus the temperature rapidly 
 falls, and uninterrupted convalescence is the rule (Fig. 31, p. 74). 
 
 // j)erforation of the uterus is suspected, the uterine cavity should 
 be lightly packed with gauze, and subsequent developments awaited. 
 // perforation is certain, and especially if the operator has dragged 
 
 1 It is needless to saj'^ that all such patients should be sent to a well-equipped 
 hospital and put in charge of a competent surgeon. But etherization is not always 
 necessary. 
 
1094 
 
 SURGERY OF THE FEMALE GENITALS 
 
 down bowel, mistaking it for retained placental tissues, the abdomen 
 should be opened at once (by a competent surgeon), and the damage 
 repaired. 
 
 Septicemia. — This may occur after full term parturition (especially 
 if instrumental), but is most frequent as the result of criminal abor- 
 tions in the early months of 
 pregnancy. There is septic en- 
 dometritis, with adherent false 
 membrane over denuded areas, 
 and purulent blood-stained dis- 
 charge, almost always accom- 
 panied by acute septic metritis, 
 evidenced by an edematous 
 boggy uterus. Infection may 
 spread to the peritoneum {peri- 
 metritis, acute septic pelvic peri- 
 tonitis, Fig. 1021) and to the 
 subperitoneal cellular tissues 
 {parametritis, acute septic pelvic 
 cellulitis). The blood sinuses in 
 the uterine walls become the 
 seat of septic thrombosis, and this 
 may extend to the uterine and 
 ovarian veins, resulting event- 
 ually in puerperal pyemia (see 
 below). Perivascular lymplian- 
 geitis may occur, and if exten- 
 sion of the thrombus to the external iliac and femoral veins takes 
 place, "milk leg" results (p. 240). 
 
 Symptoms. — The onset of puerperal septicemia occurs earlier than 
 that of sapremia, usually on the second or third day after dehvery. 
 The disease often is ushered in by a chill, and the constitutional 
 symptoms are much more severe than the local. The temperature 
 rises to great heights and falls again rapidly and at irregular intervals 
 (Fig. 28, p. 72) ; the pulse is persistently rapid and weak. Chills may 
 occur only once or twice in the course of the disease, or several times 
 daily, but at irregular intervals. Frequent chills usually indicate 
 pyemia. Unless peritonitis sets in, and except during the chills, the 
 patient suffers little; often she feels quite well, except for weakness, 
 even when most gravely ill. There may be little found in the pelvis 
 to account for the symptoms: usually the uterus is larger than normal, 
 and the discharge may be purulent, but it does not possess the foul odor 
 characteristic of putrefaction, unless sapremia was the primary condi- 
 tion. Early in the disease the uterus is not fixed, and the abdomen 
 usually is soft and full. Only if salpingitis or pelvic peritonitis exists is 
 there local rigidity and tenderness. It is when the infection is confined 
 to the extraperitoneal structures (pelvic cellulitis), that the patient feels 
 so well subjectively. By the end of the first week of the disease, 
 
 Fig. 1021. — Puerperal sepsis: Pelvic peri- 
 tonitis with suppurative perimetritis, and 
 parametritis. (After de Quervain.) 
 
PUERPERAL SEPSL^ 109;") 
 
 rari'ly earlier and ottcii iimch later, tlie uterus may hecome fixed, 
 and a pelvic mass may he detected. In some cases during the second 
 or third week the throuihosed uterine and ovarian veins may be 
 palpated in the broad ligament. 
 
 Treatment. — In every case I believe it is well to make sure that the 
 uterus retains no necrotic material. Indeed it must be confessed that 
 the diagnosis between sapremia and septicemia often cannot be made 
 until after the uterine cavity has been explored. If necrotic material 
 is found, and rapid improvement follows its removal, it usually is 
 safe to assume that the condition was one of sapremia; if on the other 
 hand, septic symptoms continue it is evident that the infection has 
 entered the uterine walls and has become systemic. Attempts have 
 been made to eradicate the entire focus of disease in these cases by 
 prompt removal of the uterus; but the mortality following the opera- 
 tion is too high to justify its employment at this stage. Some weeks 
 or months later hysterectomy may be necessary, to remove a uterus 
 riddled with abscesses. 
 
 As early as possible cultures should be made from the interior of the 
 uterus. In most cases the streptococcus is the infecting organism; 
 and if the patient is seen early enough (within two or three days of 
 onset) it may be worth while to employ large doses of antistreptococcic 
 serum, or a polyvalent serum. But unless massive doses (50 to 150 
 c.c. in twenty-four hours) are employed early in the disease, this 
 remedy appears to be useless. 
 
 Further than this, nothing remains but to provide careful nursing; 
 to ensure the taking of plenty of proper nourishment and abundance 
 of water (continuous proctoclysis, hypodermoclysis, etc.); and to 
 watch the pelvic condition. Vaginal examinations should be made 
 not oftener than once in three days; great gentleness should be used, 
 and note should be made of the mobility of the uterus, the presence 
 of a mass, or of thrombosed ovarian veins. A pelvic mass under these 
 circumstances is placed low in the pelvis, fixed to the uterus, and usually 
 on one side or the other, though often extending behind the cervix. 
 Often the abscess tends to point above Poupart's ligament (Fig. 1022). 
 Many authorities consider that all such abscesses have their origin 
 in the pelvic cellular tissues, and are entirely extraperitoneal. Some 
 of them I am sure are ordinary residual pelvic abscesses, the sequel 
 of diffuse peritonitis. The distinction is of little practical importance, 
 but a very important point is to open all such masses without invading 
 the healthy peritoneal cavity. A pelvic mass the result of gonococcic 
 infection (pyosalpinx, tubo-ovarian abscess) is placed higher in the 
 pelvis, and its onset does not date from an instrumental delivery or a 
 miscarriage (Fig. 1028). Such an abscess may be opened transperi- 
 toneally with safety, providing the operation is not done for three or 
 four months after the acute onset (p. 1075). But abscesses which result 
 from puerperal infection usually are streptococcic in origin, and if the 
 peritoneum is opened, even many years after the acute onset, fatal 
 peritonitis frequently develops. The abscess should be incised through 
 
1096 
 
 SURGERY OF THE FEMALE GENITALS 
 
 the posterior vaginal vault, or above Poupart's ligament. No opera- 
 tion should be undertaken as a mere exploration, but only when the 
 existence of suppuration is fairl}' certain. 
 
 Fig. 1022. — Puerperal sepsis: pelvic 
 abscess extending low in the pelvis and 
 pointing above Poupart's ligament. (After 
 de Quervain.) 
 
 Fig. 1023. — Double pj-osalpinx, with 
 moderate serous perisalpingitis. The 
 masses are placed higher in the pelvis 
 than those which result from puerperal 
 sepsis. (After de Quervain.) 
 
 Vaginal Pmichire. — The cervix is pulled down and forward by 
 volsellum forceps, and a transverse incision is made about two inches 
 long, just posterior to the cervix. When the vaginal wall has been 
 incised, the knife is laid aside, and the abscess is opened by the finger, 
 or b}' Hilton's method (p. 51). The cavity is drained by gauze and 
 rubber tube. 
 
 Extraperitoneal Incision. — If the abscess points near Poupart's 
 ligament, it is easily evacuated through a small IMcBurney incision. 
 When the layers of the abdominal wall have been incised, great care 
 is required not to injure the peritoneum, or to break up isolating 
 adhesions if the abscess is intraperitoneal in origin. The surgeon 
 should burrow down cautiously along the pelvic wall until pus is 
 found. The abscess ca\'ity is then drained by rubber tube and gauze. 
 
 Pyemia. — Puerperal pyemia, as already noted, results from the 
 detachment of septic emboli in the peri-uterine veins. Repeated 
 chills, and the appearance of metastatic foci of infection are the 
 two main diagnostic points. Embolic pneumonia is frequent. Other 
 foci are less usual, but recovery may ensue after multiple arthritis, 
 conjunctivitis, subcutaneous abscesses, and even after cerebral 
 embolism. 
 
OVARIAX AND PAROVAIilAN CY.'^TS 1097 
 
 Trcatincnt. — Whoii throiiihost'd ovuriuii veins can he felt on vaginal 
 examination, and the cHnical symptoms of pyemia, especially recurring 
 chills, are j)resent, it has heen ])ro]><)se(l to f)pen the abdomen and 
 ligate the veins ahove the limits of thr()nil)Osis, or even to excise the 
 infected thromhi, as is done in jugular thrombosis (p. 240). The 
 operation, though it may be difficult, is seldom impossible; but some- 
 times the thrombus is found to extend so high (to the renal veins 
 or \ena ca\a) or may involve so many trunks (internal, common and 
 external iliac), that the operation will have to be abandoned. But 
 as the mortality following this operation, in collected statistics, varies 
 from 20 to 55 per cent.,' and the general mortality of the condition 
 for which it is recommended is from 55 to 80 per cent., in cases treated 
 without operation, it is apparent that in carefully selected cases it is 
 a procedure worthy of careful consideration. 
 
 TUMORS OF THE FEMALE GENITAL TRACT. 
 
 Ovarian and Parovarian Cysts and Tumors. — Ovarian Cysts may 
 be classified as retention cysts and cystadenoinas. Dermoid cysts 
 (teratomas) are discussed at p. 1101. 
 
 Retention Cysts of the Ovary. — Reference has already been made, 
 at p. l07cS, to cystic degeneration of the ovaries, usually associated with 
 chronic ovaritis, and probably due to thickening of the stroma; the 
 cysts usually are small, multiple, and appear not only on the surface 
 of the ovary, but are scattered throughout its structure (Fig. 1005). 
 Apart from the associated lesions, they produce no symptoms and 
 require no treatment. 
 
 A retention cyst of the Graafian follicle usually is larger than the 
 cysts found in cystic degeneration of the ovary; it almost always is 
 single, and is attached to the ovary by a rather wide base. It is lined 
 by cylindrical epithelium, but in the larger cysts this becomes atrophied 
 from pressure. If it is large enough to produce symptoms, the differ- 
 ential diagnosis from tubal and other ovarian enlargements becomes 
 important. Usually it is found to be the size of a hen's egg or small 
 orange, and freely movable in the pehis, though attached by a pedicle 
 to the uterus. Its contents are clear, unless blood-stained from intra- 
 cystic hemorrhage. Intraperitoneal rupture, with or without bleeding, 
 may occur; and if bleeding is profuse the condition resembles that 
 seen in ruptured ectopic pregnancy and requires the same treatment. 
 Excision of the cyst and suture of the defect in the ovary is the proper 
 treatment for the unruptured cyst; removal of the entire ovary is 
 undesirable unless the patient has reached the menopause. 
 
 The corpus luteum cyst is another type of retention cyst of the ovary. 
 The contents usually are dark and tarry, and the cyst wall is not 
 tense. Without histological examination, which shows typical lutein 
 cells (pigmented round cells) but no epithelium in the lining membrane, 
 
 ^ Michels in 1909 collected 64 such operations, with 31 deaths (48 per cent.); 
 but J. W. Williams (1909) reported 5 cases in his own experience with only 1 death. 
 
109S SURGERY OF THE FEMALE GENITALS 
 
 the diagnosis from the Graafian follicle cyst is uncertain. The cyst 
 shoiikl be excised and the defect in the ovary sutured. 
 
 Tubo-ovarian Cysts may occur in connection with any variety of 
 ovarian cysts, but are especially frequent in the case of retention cysts. 
 They may follow tubo-ovarian abscess (p. 1077). 
 
 Cystadenomas of the Ovary. — These are true neoplasms. Two main 
 varieties are recognized: the simple (pseudomucinous) cystadenoma, and 
 the papuliferous cystadenoma. 
 
 Simple Cystadenoma. — These are the typical "ovarian cysts." 
 Nowadays they rarely reach the immense size formerly encountered, 
 when the tumor not infrequently weighed more than the patient, since 
 operation is resorted to while the cysts are still of reasonable size. 
 
 Usually only one ovary is affected. The cyst originally is multi- 
 locular, but the smaller cysts frequently coalesce to form larger com- 
 partments, and incomplete partitions may be the only evidence of 
 the former multilocular state. The cyst walls are hned by cylindrical 
 epithelium in a single layer; stratification of the epithelium is rare and 
 may indicate a malignant tendency. In the cyst walls are found down- 
 growths of epithelium, forming simple or compound gland tubules. 
 The fluid within the cysts is viscid, glairy, or mucinous, and its color 
 varies from clear yellow to turbid or brownish. From their contents 
 the cysts often are termed pseudomucinous. The ovary is compressed, 
 atrophied, and may be entirely destroyed by the pressure of the cyst. 
 The two most frequent complications are rupture of the cyst, and torsion 
 of its pedicle. If rupture occurs there may be marked shock, but this 
 is rare; usuahy the fluid is absorbed, and temporary polyuria may be 
 noted; in other cases peritonitis develops. Occasionally after rupture 
 portions of the cyst lining become engrafted in various parts of the 
 abdominal cavity, and numerous small cysts develop (pseudomyxomu 
 peritonei). Torsion of the pedicle is a very serious accident, which occurs 
 in about 10 per cent, of cases. It is especially frequent in dermoid cysts 
 (p. 1101). The symptoms are severe pain, shock, and sudden increase 
 in size of the tumor (perhaps previously not known to exist). This 
 sudden increase in size results from venous obstruction in the pedicle, 
 causing serous and bloody transudation in the cyst. If the twist 
 is tight enough, gangrene, with slowly developing peritonitis, may 
 occur. Prompt operation is indicated in all cases. 
 
 Even if no complications occur, the clinical course of an ovarian 
 cyst is invariably toward the death of the patient. Ovarian cysts 
 grow rapidly, and usually life is terminated witliin comparatively 
 few years unless the cyst is removed by operation. 
 
 PAPiLLiFERors Cystadexoma. — This growth frequently' affects 
 both ovaries, is more often unilocular than multilocular, often develops 
 between the layers of the mesosalpinx, and rarely attains very large 
 size. The cyst wall is lined by cylindrical-celled epithehum, usually 
 not stratified, but always bearing intracystic papillomas. The con- 
 tained fluid is thin and serous, rarely blood-tinged. At the time of 
 operation fuUy 50 per cent, of these tumors are already carcinomatous, 
 
OVARIAN AND PAROVARIAN CYSTS 
 
 1009 
 
 unci it is liiglily prol);iljle tliiit all would become iiiuligiuuit if not 
 removed. The continuous growth of the intracystic papillomas leads 
 to distention of the cyst and fr(>([U(Mitly causes its rupture, whereupon 
 the growth becomes grafted on neighboring structures in the abdomen, 
 and ascites frccpiently results. Seconddry myxomatous or calcareous 
 degeneration may occur. 
 
 Fig. 1024. — Diagram of ovary and parovarium. 
 
 Parovarian Cysts. — The parovarium or epoophoron lies in the broad 
 ligament between the ovary and Fallopian tube. It is formed by 
 the remains of the Wolffian body (Fig. 1024), and is composed of a 
 longitudinal tube (Gartner's duct), and transverse tubules w^hich run 
 from the hilum of the ovary to join the longitudinal tube. The 
 Hydatid of Morgagni, which is present in about 50 per cent, of females, 
 is recognized as the lateral continuation of the longitudinal duct; it 
 enters the broad ligament on its anterior surface between Fallopian tube 
 and ovary. Kobelt's tubules are the aberrant tubules of the Wolffian 
 body between the hydatid of Morgagni and those tubules which 
 enter the hilum of the ovary. Any of these tubular structures may 
 become the seat of cystic formation. Cysts arising from the hydatid 
 of Morgagni and from Kobelt's tubules usually are small, are attached 
 to the lateral border of the broad ligament by a more or less distinct 
 pedicle, and seldom produce symptoms; they are to be distinguished 
 from myxomatous and cystic degeneration of the fimbriae of the Fal- 
 lopian tube. 
 
 The typical parovarian cyst forms about 10 per cent, of all cases of 
 ovarian cyst. It develops and spreads within the folds of the broad 
 ligament (hence it is known as the "broad ligament cyst"), almost 
 alwaj'S is unilocular, grows slowly, and seldom attains very great size. 
 Its contents are clear, "like spring water," and the cyst wall is lined 
 with a single layer of cylindrical epithelium. It is easily distinguished 
 from an ovarian cyst because it is independent of the ovary, is covered 
 by peritoneum, possesses a double layer of vessels on its surface (one 
 belonging to the peritoneum and the other to the cyst w^all), usually 
 is easily enucleated (rarely forming adhesions), possesses no distinct 
 pedicle, and almost invariably has the Fallopian tube stretched out 
 over its surface at some distance from the ovary. 
 
1100 
 
 SURGERY OF THE FEMALE GENITALS 
 
 Symptoms and Diagnosis of Ovarian and Parovarian Cysts. — Few 
 symptoms are present unless the eyst is of such a size as to become 
 impacted in the pelvis, or unless it is so large and of such long dura- 
 tion as to have induced cachexia, when the typical fades ovariana is 
 seen (Fig. 1025). In most cases the cyst is discovered by accident, or 
 the woman comes to the surgeon because of increase in size of the 
 abdomen. Ovarian cysts are commonest from forty to fifty years of 
 age. 
 
 Fig. 1025. — Malignant suppurating ovarian cyst in a woman, aged fifty-seven years; 
 duration of illness seven j-ears. Was tapped for ascites several years ago. Tumor 
 cystic with solid masses; abdominal circumference, with patient recumbent, was 49 
 inches. Weight 149 pounds (normal weight 126 pounds). Inoperable. Episcopal 
 Hospital. 
 
 If the tumor is small it is felt as a smooth, round, tense, fluctuating, 
 movable, and usually painless tumor, attached to the uterus by a 
 pedicle. Differential diagnosis from other tubo-ovarian lesions depends 
 chiefly on the clinical history. 
 
 // the tumor is of medium size (fetal to adult head) it usually rises 
 out of the pelvis and is appreciated as an abdominal growth. The 
 diagnosis must be made from uterine fibroid and other pelvic tumors. 
 The cyst lies posterior to the uterus (a distended bladder lies in front), 
 and it often is possible to determine that the uterus is of normal size. 
 In most cases the pedicle of an ovarian cyst can be detected, but this 
 may require abdomino-rectal palpation, while one assistant draws 
 the uterus down into the vagina by a tenaculum and another assistant 
 draws the tumor as far as possible out of the pelvis into the abdomen. 
 If a pedicle is absent (intraligamentary cyst) the distinction from a 
 subperitoneal fibroid may be very difficult, depending chiefly on the 
 clinical history. 
 
 When the tumor becomes very large, ascites is the chief condition which 
 simulates it. But in ascites there usually is some organic cause for 
 the condition, and the latter has developed suddenly; the abdomen 
 is flat on the top and bulging in the flanks; its outline does not rise 
 abruptly from the pubis as is the case in ovarian cyst (Fig. 1025); 
 the umbilical area is resonant, the navel pouts, and there is shifting 
 dulness in the flanks. 
 
OVARIOTOMY 1101 
 
 Dermoid Cysts (Teratomas) develop from the ^'crmiiial cells of the 
 ovary. Under this term are classed both sini})Ie dermoid cysts, which 
 contain only normal skin products (secretions of sweat and sel)aceous 
 glands, hair, nails, and teeth), and coviylicated dermoid cysts, in which 
 may he found also bones, cartilage, muscle, and other more or less 
 fully formed structures (embryomas). Dermoid cysts frequently 
 art'cct both ovaries, and may begin to grow at any age (often in children 
 and young girls). When growth begins it usually is rapid; but if the 
 cyst remains small it may cause no symptoms unless it becomes infected 
 or undergoes carcinomatous change (both are frecjuent complications) 
 and may last for a lifetime. Usually the cysts are adherent and should 
 l)e treated as if malignant. 
 
 Solid Tumors of the Ovary are comparatively rare. They are 
 frecjuently bilateral. The most important are the malignant tumors: 
 the carcinomas clinically resemble the papuliferous cystadenomas; in 
 many cases they are secondar^• to carcinoma elsewhere (stomach, 
 breast, uterus, liver, etc.) being grafted on the germinal epithelium 
 of the ovary through the medium of the omentum. Blood-stained 
 ascitic fluid is frequently present. Sarcoma usually occurs at a younger 
 age. Of the benign tumors, fibroma is most often encountered ; it may 
 occur at an early age, but seldom causes sj^mptoms except from its 
 weight or from pressure if impacted in the pelvis. 
 
 Treatment. — All such growths should be removed, unless clearly 
 inoperable. 
 
 Ovariotomy. — This is the classical operation for the removal of an 
 ovarian cyst (Ephraim IMcDowell, 1809). If the cyst is so small as 
 to be delivered easily through an ordinary abdominal incision, the 
 operation resembles that described as oophorectomy^ or salpingo- 
 oophorectomy (p. 1079) ; the tube may or may not be removed with 
 the diseased ovary. But in cases where the tumor is very large, the 
 technique of the operation is different. A hypogastric paramedian in- 
 cision is made, and the peritoneal cavity opened; if the cyst is thought to 
 be malignant (papuliferous cystadenoma, dermoid) every effort should 
 be made to prevent its rupture; these cysts seldom are immensely 
 large, and usually may be delivered through an incision of moderate 
 size. In every case of malignancy both ovaries should be removed. 
 In the case of an immense cyst, however (usually a simple cystadenoma) , 
 it is best to tap the tumor so as to enable it to be removed through 
 an incision of ordinary size. After the cyst wall is exposed, the pre- 
 senting surface of the tumor is isolated by gauze packs, and a large 
 blunt pointed cannula (at least 1 cm. in diameter) with rubber tube 
 attached, is thrust into an avascular area of the cyst wall, and the 
 contents are removed by syphonage. If the cyst is multilocular it 
 may be necessary to tap several loculi; usually a sufficient number 
 may be reachcfl from the interior of that first emptied without with- 
 drawing the cannula. As the cyst walls collapse they are to be drawn 
 
 ' This of course is a more correct term etymologicaUy, but long usage sanctions 
 the use of the term ovariotomy for the tyjjical operation for large ovarian cysts. 
 
1102 SURGERY OF THE FEMALE GENITALS 
 
 into the wound with volselhim forceps, and an assistant is to make 
 pressure on the flanks, so as to prevent leakage into the abdominal 
 cavity. When the entire tumor has been withdrawn the pedicle 
 comes into view. If there are adhesions, the operation is much more 
 difficult, and careful dissection may be required to free the tumor from 
 omentum, mesentery, intestine, etc. When the pedicle has been 
 brought into view, it should be caught in strong crushing forceps, 
 and ligated by transfixion in the groove thus made. The pedicle 
 usually is composed of broad and round ligaments. Fallopian tube, 
 and infundibulo-pelvic ligament. Great care should be taken to see 
 that hemostasis is complete; when they can be identified the ovarian 
 and utero-ovarian arteries should be tied separately. Finally the 
 stump of the infundibulo-pelvic ligament should be united to the 
 stump of the tube, and denuded areas should be covered by peri- 
 toneum. Before closing the abdomen always examine the other ovary. 
 
 If the intestines are carefully protected from exposure and the 
 patient's bodily heat maintained, the operation is attended by very 
 little shock. The mortality in expert hands is below 5 per cent. 
 
 Fibroids of the Uteras. — These tumors are fibro-myomas; those 
 with an excess of fibrous tissue justly merit the term fibroids, but in 
 general this term and myoma or fibromyoma are used indiscriminately, 
 regardless of the amount of fibrous tissue present in the tumors. The 
 tumors usually are multiple, and spring from the uterine wall, prob- 
 ably, it is believed, from the walls of bloodvessels. Thej' occur with 
 greatest frequency in the body of the uterus, fibroids of the cervix 
 being comparatively rare. By some the affection is considered a wide- 
 spread disease, with one of its local manifestations in the uterus; and 
 they explain the frequently accompanying myocardial changes in this 
 way. Some authorities teach that the tumors always have a congenital 
 origin; it is undisputed, however, that they seldom begin to produce 
 symptoms or are discovered until well into the child-bearing period, 
 from thirty-five to forty-five years of age. A woman with fibroids 
 usually is sterile, and it is disputed whether sterility is to be regarded 
 as a cause or a result of the existence of fibroids. If pregnancy 
 occurs it is very apt to result in abortion or miscarriage. Fibroids 
 are especially common in the negro race. 
 
 The tumors begin as interstitial growths, within the walls of the 
 uterus ; they may remain in the uterine wall even when attaining very 
 large size, but usually they tend to push their way through to the 
 sub peritoneal or the submucous surface of the uterus. In many cases 
 tumors are found in all three locations. They may present beneath 
 the peritoneum or mucosa as sessile gro^-ths, but not infrequently 
 a pedicle forms. Then the tumor, if subperitoneal, may become adher- 
 ent to neighboring abdominal structures, as the result of attacks of 
 congestion and inflammation from torsion of the pedicle; and in rare 
 instances these secondary adhesions may become so firm that the 
 pedicle ruptures and the migrated fibroid continues to receive its 
 nourishment through the adhesions alone. Submucous fibroids 
 
FIBROIDS OF THE UTERUS 
 
 1103 
 
 frof(n(Mitly tlovelop {)e(lides, and present in tlie uterine eavity or pro- 
 trude from the eervix in the form of poJyjd. Usually only one polypus 
 is i)resent, si)ringin<;' from the eervix or near it, and mostly fibrous in 
 
 Fig. 102G. — Fibroids of the utirn.<, siiln.ci 
 years. (See Fig. 1U27.) 
 
 f lineal and interstitial; age fifty-three 
 Episcopal Hospital. 
 
 Fig. 1027. — Uterine fibroids, specimen shown in Fig. 1026 sectioned, exposing inter- 
 stitial growths, one of which has undergone cystic degeneration. Note also carcinoma 
 of the cervix, with its crater-like excavation; a rare complication of fibroid tumors. 
 Episcopal Hospital. 
 
1104 
 
 SURGERY OF THE FEMALE GENITALS 
 
 structure. If a polypus springs from the fundus of the uterus, the 
 uterine wall becomes thinned at the point of attachment, and inversion 
 of the uterus may occur. 
 
 Symptoms. — In many cases no symptoms whatever are produced 
 until the tumors become so large as to cause pressure effects. Among 
 the most usual of these are vesical irritability, hemorrhoids and inter- 
 ference with defecation, pain in the sacrum and coccyx, varicose 
 veins or edema from interference with the circulation of the lower 
 extremities, renal disturbances from pressure on the ureters, etc. 
 Interstitial grouihs may cause no noticeable change in the form of the 
 uterus, though it may be much larger than normal, and the depth 
 of its cavity will be increased; but a sound should not be introduced 
 without due consideration, particularly until the possibility of preg- 
 nancy has been absolutely eliminated. Dysmenorrhea is present in 
 
 Fig. 1028. — Prolaj'-' : - . iiniinus fibroid :?iranL'ul ;; -i \sith complete inversion 
 of vagina — uterus not invtrted. Age forty-three years. Had normal childbirth two 
 j'ears ago, and no symptoms from fibroid until prolapse occurred, twenty-three hours 
 before operation (vaginal hysterectomy). Death from peritonitis five days after 
 operation. Episcopal Hospital. 
 
 some cases of interstitial growi;hs. Subperitoneal growths usually 
 may be recognized by bimanual palpation; they may be of various 
 sizes and shapes, but are attached to the uterus, move with it, and 
 usually are high in the pelvis, not in the position where pus tubes 
 are found; unless the tumor is very large, or impacted in the pelvis, 
 the tumor is not fixed. Submucous grouihs are particularly charac- 
 terized by profuse and prolonged menstrual bleeding; intermenstrual 
 hemorrhage is rare, though bleeding may last from one period to the 
 next and continue through this; then an intermission may occur until 
 the normal time for the occurrence of the next menstruation which 
 will also be unduly prolonged. Anemia is a frequent result and may 
 be severe. Sometimes submucous tumors may be detected by the 
 introduction of a finger into the os, which frequently is patulous. 
 Attacks of colicky pain may be caused by efforts of the uterus to 
 force the tumor through the cervix. Complications: Occasionally a 
 
FIBROIDS OF rilF rTERl'S llOo 
 
 larjje sul)niuc()iis fibroid proldp.sr.s- tlir()iiji;li the \;i^iiia, and may cause 
 invcrjfion of tliis structure or eveu of the uterus itself. Sfranyulation 
 of the i)r()hii)sed fibroid may occur, resultiufj in (/angrene, a very 
 serious compHcatiou ( Fi^^ 1()2S). Fil)rous j)ol>pi are less serious than 
 Iar<i-er myomatous sul)uuicous tuuiors, rarely causing alarming hleed- 
 inj;. Vet the presence of any submucous growth predisposes to infec- 
 tion of the endometrium, and this readily extends to the tubes, so that 
 hy(lrosali)inx, as already noted (p. 1077), is a frequent complication. 
 Or infection may spread directly to the tumor mass, causing a very 
 serious form of septic metritis. 
 
 Diagnosis. — This is made from attention to the history of the case, 
 from observation of the symptoms, and, most important of all, from 
 the ph\sical examination. It is especially important in every case 
 to exclude the presence of pregnane}/: a large interstitial m>'oma, par- 
 ticularly if softened as the result of passive congestion with edema, 
 may so closely simulate pregnancy as to deceive even the elect. Too 
 much reliance should not be placed on the history in such cases, if 
 it is impossi})le to corroborate the patient's tale; many women would 
 be pleased to be relieved of a pregnancy by hysterectomy, and are 
 wilfully deceitful. Usually, however, in pregnancy the cervix is softer, 
 the uterus feels more cystic, the menses are absent, and always (if 
 the policy of "waiting and watching" is followed) indisputable signs 
 of pregnancy will declare themselves in time. An ovarian cyst may 
 closely resemble a fibroid of the uterus if it is \'ery tense, and particu- 
 larly if intraligamentary; in some cases nothing short of an exploratory 
 operation will clear the diagnosis. In the case of pyosalpin.v the history 
 is dift'erent ; the mass usually is posterior to the uterus and fixed ; there 
 is more leucorrhea than in fibroids, and menstruation is irregular 
 rather than prolonged or profuse. The diagnosis from carcinoma 
 and other malignant tumors rarely is difficult. 
 
 Adenomyoma of the uterus occurs in 5 per cent, or more of cases. 
 The glandular elements are derived either from the endometrium 
 (Cullen, 1903), or from remnants of the Wolffian body in the walls 
 of the uterus (von Recklinghausen, 1896). The tumors frequently 
 are infiltrating in character, but occasionally subperitoneal more or 
 less encapsulated growths develop, or even polypi. Cyst formation 
 is the only form of degeneration which is common. The symptoms 
 are much the same as in cases of ordinary fibroids, and the diagnosis 
 seldom is made except in the pathological laboratory. The existence 
 of this ^'ariety of myoma may be suspected, however, if the tumor 
 is very adherent, and particularly if it is cystic and the contents of 
 the cysts are chocolate colored (menstrual fluid). The proper treat- 
 ment is hysterectomy. 
 
 Prognosis. — The prognosis of uterine fibroids is not good. Until 
 some symptoms are produced, the growths often pass undiscovered. 
 But, when symptoms of any kind once have appeared, it is rare for 
 the patient ever again to be free from discomfort. The menopause 
 is indefinitely deferred, and the tumor usually continues to grow. 
 70 
 
1106 SURGERY OF THE FEMALE CEXITAL.^ 
 
 Not to mention various degenerations (calcareous, myxomatous, 
 cystic, hyaline, malignant* of the tumors, which occur in about 20 
 per cent, of cases, and the ever-threatening degeneration of the 
 cardiac muscle, which is almost inevitable, the woman is subject 
 to the dangers of hemorrhage, miscarriage, sepsis, inversion of the 
 uterus, etc. 
 
 Treatment of Uterine Fibroids. — We liear reports lately of favoraV)le 
 results secured l^y .r-ray- and radium treatment, just as some years ago 
 much was heard of the electric treatment advocated by Apostoli, and 
 even before that time of the curative \alue of ergot. Whether these 
 new departures will prove more lasting than their predecessors time 
 alone can show; but for the present and immediate future at least, the 
 treatment advised and practised by rational surgeons is operative. 
 The tumors should he removed. In some comparatively young women 
 who are anxious to l)ear children, it may be justifiable to remove the 
 individual tumors, leaving the main bulk of the uterus intact. This 
 is especially the case when a pol\-pus is present, without other demon- 
 strable growths. Polypi may be removed through the vagina after 
 the division of the |)edicle by scissors or by formal excision from the 
 uterine wall. Temporary division of the cervix may be necessary. 
 Bleeding from the stump of the polyp rarely is severe and may be 
 controlled by packing if suture is impossible. Isolated subperitoneal 
 growths may be removed by excision and enucleation through an 
 abdominal wound: the operation is known as myomectomy. The objec- 
 tions to it (largely theoretical) are that other tumors almost surely 
 are overlooked and will subsequently give rise to trouble; that even 
 should pregnancy follow it is very apt to be terminated prematurely; 
 and that should pregnancy continue to term, grave complications 
 may arise during parturition or the puerperium from other fibroids 
 which have grown during the pregnancy. But in a small proportion 
 of cases, carefully selected, the operation is of value. 
 
 In the great majority of cases removal of the uterus {hysterectomy) 
 is preferable. This may be accomplished by the vaginal route (raginal 
 hyst£rertomy) if the uterus is small; but in most cases the abdominal 
 ojjeration is required. If the uterus is amputated above the cervix 
 the operation is known as .nipraraginal hysterectomy; if the cervix also 
 is removed the proper term is pan-hysterectomy. In most cases the 
 tubes and ovaries are removerl also {complete supraAaginal or pan- 
 hx'sterectomy i . 
 
 Abdominal Hysterectomy. — The fundus of the uterus is drawn through 
 the abdominal wound by volsellum forceps, and one broad ligament 
 is exposed by flrawing the tumor well to the other side. Clamps 
 may then be applied to both sides of the proposed section, leaving 
 the adnexa attached to the uterus if they are diseased (Fig. 1029). 
 In many cases it is simpler to ligate the ovarian vessels at once, 
 applying clamps only to the uterine side of the broad ligament. 
 Hemorrhage being thus controlled, the broad ligament is divided 
 with scissors down to the level of the cervLx, but not far enough to 
 
IIYSTEHECTOMY 11(1- 
 
 wound X\w uterine jirtery, wliicli lias not yet hccn secured. The roinid 
 ligament is tlien Heated close to the uterus, and di\ided hetween the 
 ijiiaturc and uterus. The tumor is then pulled to the patient's other 
 side, and the broad and round ligaments are divided as on the first side. 
 'J'his frees the uterus so that in most cases the cervix can he drawn 
 up into the ahdominal wound. The tumor is then turned backward, 
 and an incision is made from one round ligament to the other some- 
 what above the vesical reflection of peritoneum. The peritoneal flap 
 thus formed is pushed away from the cervix by gauze dissection, 
 until at the sides of the cervix the uterine vessels are exposed. These 
 
 Fig. 1029. — Diagram to show technique of abdominal panhysterectomy: on the 
 right of the pictuie the left ovary and tube are being removed with the uterus; the 
 right ovary is not being lemoved. Ligatures have been placed on the ovarian and 
 uterine arteries and on the round ligaments on both sides, and the tissues close to the 
 uterus have been clamped. The anterior vaginal fornix has been opened exposing the 
 cervix. 
 
 are clamped close to the uterus and ligated not more than half an 
 inch distant; the ureter crosses under the uterine artery about three- 
 quarters of an inch (2 cm.) distant from the cervix. The uterine vessels 
 are then divided on both sides, between clamp and ligature. The 
 uterus is then turned well forward over the pubes, and an incision 
 is made across its body above the pouch of Douglas, from one broad 
 ligament attachment to the other; and the jieritoneal flap thus formed 
 is pushed downward by gauze dissection. Finally the cervix is cut 
 through with scissors in funnel shape, and the uterus is removed. 
 The cervical canal is then closed with catgut sutures, and the stumps 
 
1108 
 
 SURGERY OF THE FEMALE GENITALS 
 
 of the round and broad ligaments are sutured to it, so as to support 
 it in proper position. Then the peritoneal flaps front and back are 
 united over the cervical stump, closing in all areas denuded of peri- 
 toneum. In most cases the abdomen is closed without drainage. 
 
 If it is desired to remove the cervix also, the dissection must be carried 
 a little deeper; then the Aaginal vault is divided. The surgeon must 
 look for bleeding from the vaginal arteries and secure a dry field 
 before proceeding. Finally, the stumps of the round and broad 
 ligaments are implanted into the vaginal vaidt. 
 
 Vaginal Hysterectomy. — This is suitable only in cases where the 
 tumor is small, and the vagina sufficiently relaxed. A self-retaining 
 speculum is used (Fig. 1002), and the cervix is closed by sutures or 
 by a double tenaculum forceps, and drawn outside the vulva. An 
 incision is next made all around the cervix, through the mucosa; 
 the incision in the anterior cul-de-sac is deepened, pushing the 
 
 Fig. 1030. — Diagram of vaginal hysterectomy, showing application of clamps 
 to the broad ligaments. 
 
 bladder wall and with it the ureters well upward and forward, 
 until the peritoneal cavity is opened. A finger is then inserted 
 into the pelvic cavity and passed behind the cervix, and on this 
 finger as a guide the posterior vaginal cid-de-sac is further incised 
 until the peritoneal pouch of Douglas is opened. Gauze is then 
 packed into this opening to keep the intestines from prolapsing 
 into the wound. Any bleeding is easily controlled by hemostats. 
 If the tumor is not too large, the fundus of the uterus may now be 
 hooked down by the finger and brought out through the incision in the 
 anterior vaginal cul-de-sac. If this can be accomplished the broad 
 ligaments may then be ligated from their ovarian border downward 
 to the cervix, as in supravaginal hysterectomy. If the fundus of the 
 uterus cannot be deli^Tred in this way, the broad ligaments are clarnped 
 from below upward, not more than half an inch distant from the 
 cervix, removing the tubes and ovaries also if they are diseased (Fig. 
 
CAiicixoMA or riiK iTh'h'rs 1109 
 
 lOlU)). Thv hroiid li<;;iin('iits arc then cut tliroiijili hctweeii tlic clamps 
 and the uterus; and the iKTitoneum is closed, the ^auzc pack heiiij; 
 removed as the last peritoneal suture is tied. After carefully lif^ating 
 the broad liiianients, their stumi)s arc sutured to the vaginal \ault. 
 A uau/.c drain is left in the \a^ina. The o])cration mav he done also 
 without ligatures, leaving the clamps on the broad ligaments for se^■eral 
 days. Si)ecial clamps, with detachable handles, hnvv been de\ised 
 for this ])ur|)ose. 
 
 Carcinoma of the Uterus. This is exceedingly common, especially 
 in the cer\i\. Only al)out o to 10 per cent, of cases occur in the body 
 of the uterus. In the cervix the growth almost always is a squamous- 
 celled ejMthelioma, though carcinoma of the glandular type (adeno- 
 carcinoma) sometimes occurs; while in the body of the uterus the 
 tumor, with a very few rare exce])ti()ns, is an adenocarcinoma. Most 
 patients are in the fourth decade of life, approaching or past the meno- 
 pause; almost all have borne children, and many have had lacerations 
 of the cer\ix which have not received proper treatment. 
 
 Carcinoma of the Cervix occurs in two forms: (1) as an evertiity, vef/e- 
 tat'uHj, proliferating, or cauliflower-like growth; or (2) as an invert lug, 
 infiltrating, and contracting growth. At an early stage of the disease 
 these two types are quite distinct, but later the carcinomatous tissue 
 tends to become necrotic, and when sloughs have been shed the cervix 
 is represented only by a crater-like cavity filled with purulent debris 
 (Fig. 1027). The everting type is more easily recognized at an early 
 date, owing to the papillary excrescences w^hich form; wdiereas in the 
 infiltrating type very extensive invasion of the cervical tissues may 
 occur before there is much alteration in the appearance of its vaginal 
 surface. 
 
 Extension occurs to all surrounding tissues, but in no definite order. 
 The bases of the broad ligaments frequently are invaded early, so 
 that the uterus becomes fixed; the ureters are surrounded and may 
 become compressed by the growth; the pelvic lymphatics up to and 
 even beyond the bifurcation of the aorta are invaded ; sometimes exten- 
 sion to the inguinal lymphatics occurs; the growth extends locally 
 into the vaginal vault, and the bladder and even the rectum may be 
 infiltrated, so that late in the disease distressing vesico-vaginal fistula^ 
 (rarely recto-vaginal) may form. In most cases the uterine body 
 remains free of disease, the carcinomatous growth rarely extending 
 abo^•e the level of the internal os. 
 
 Symptoms. — These usually are absent or are overlooked until the 
 disease is quite far advanced; only from 10 to 20 per cent, of patients 
 applying for treatment are susceptible of cure. The most important 
 symptom, and usually the earliest, is bleeding, especially intermenstrual 
 or occurring after the menopause, l^sually this bleeding occurs spon- 
 taneously, and is moderate or apparently insignificant in amount; 
 it may follow coitus or defecation; occasionally it is profuse and pros- 
 trating. Such a sudden and alarming hemorrhage almost always is 
 due to carcinoma and not to fibroids. The bleeding is painless as a 
 
niO SURGERY OF THE FEMALE GENITALS 
 
 rule, and unless the woman notes its occurrence and submits to \agiual 
 examination, she may go along for months before anything further 
 occurs to call attention to her condition. There may he, indeed 
 there usually is, a certain amount of Icitcorrheu; and the serous, watery, 
 or blood-stained character of this, and at a later period its fetor, ma\' 
 arrest her attention. Pain is a late and unimportant symptom; it 
 rarely is severe until the sacral plexus is in\'()lved and the tumor 
 entirely inoperable. 
 
 The disease may thus be divided clinically into three stages: (1) the 
 stage of occasional hemorrhage; (2) the stage of gradual decline of health, 
 ivith fetid leiicorrhea; and (8) the inoperable, hopeless stage, with excru- 
 ciating pain, and disgusting odor, the patient's condition being loath- 
 some to herself and all about her. The a\'erage duration of the disease 
 from first symptoms to death averages from fifteen to twenty months. 
 
 Carcinoma of the body of the uterus presents the same symptoms, 
 but they develop at a much later period, and are not attended by any 
 definite physical signs, except slight enlargement of the uterus. It is 
 much more frequent in women who haAe borne no children than 
 carcinoma of the cervix. 
 
 Diagnosis. — Every woman whose symptoms suggest the mere pos- 
 sibility of the disease should be submitted to a competent surgeon 
 for a most painstaking vaginal examination; any alteration in the 
 cervix, especially if bleeding is easily aroused, should be regarded as 
 suspicious, and a section should be taken for microscopic study. 
 This is easily done after swabbing the cervix inside and out with 10 
 per cent, eucain solution; the section (removed with knife or scissors) 
 should extend from the cervical canal into apparently healthy tissue, 
 and should be submitted to a pathologist for prompt report. If a 
 carcinoma of the uterine body is suspected, the curette should be 
 used, and the scrai)ings mounted and examined histologically. 
 
 Treatment. — A radical operation, similar in scope to that practised 
 in cases of carcinoma of the breast, and involving removal of the pelvic 
 lymph nodes and connective tissues in one mass with the diseased 
 uterus, was systematized in 1S95 by Ries, elaborated by Sampson, 
 and popularized by ]\Iackenrodt, Wertheim, and others; })ut while 
 in theory this procedure is correct, it is found that the immediate 
 mortality even in the hands of skilled gynecological operators is about 
 25 per cent. An inexperienced surgeon will not be able to do a com- 
 plete operation, and in his attempt to be ultra-radical probably will 
 do more harm than good. ]Many investigators claim that a truly 
 radical operation is impossible, and point out that autopsies have 
 shown that whenever carcinomatous lymph nodes were removed at 
 operation, others were overlooked. It seems to me that we must 
 look upon these radical methods as still upon trial, and only to be 
 attempted by exceptionally skilled and experienced operators in 
 carefully selected cases. JVhen the uterus is not fixed its removal by 
 the ordinary method of pan-hysterectomy (p. 1106), paying special 
 attention to wide excision of the vaginal vault, but without attempts 
 
CIlOh'lO-l'H'I'I'llh'LIOMA MALKISUM 1111 
 
 to dissect tlu' |)i'l\ic lyinpli nodes, is :iii operjitioii not attended hy an 
 unjustiliaMe |)riniary mortality; and inan\ patients so treated will 
 he restored temporarily to health and enjoyment of life; anil ulien 
 recurrence or metastasis takes jjlaee, as it almost surely will, the 
 condition will he much less distrossiiifi; than if no operation had 
 heen performed. 
 
 # 
 
 \ 
 
 Fig. 1031. — Cborio-epithelioma maligmim, in a patient aged forty-two years. Diag- 
 nosis made from microscopical examination of scrapings from endometrium ten days 
 after an abortion. Immediate hysterectomy. Episcopal Hospital. 
 
 When the uieriis is fixed, and its removal appears impossible, the 
 patient's comfort may be greatly promoted and her life prolonged 
 by scraping away the cervical growth with a curette, and cauterizing 
 its base thoroughly with the actual cautery. This palliative operation 
 may be repeated every few months, and may be used in cases of recur- 
 rence after hysterectomy. It deserves to be employed with more 
 enthusiasm than is usually accorded to ])alliative operations. 
 
 Chorio-epithelioma, or Deciduoma Malignum (Sanger, 188S), is 
 an exceedingly malignant tumor growing in the body of the uterus 
 after pregnancy. The pregnancy frequently is terminated before 
 term, and the most favorable cases are those in which the diagnosis 
 is made by the pathologist from examination of retained tissues 
 removed in such cases (Fig. lOl^l). Such examination never should be 
 neglected. The tumor probably arises from the chorionic and not 
 from the decidual tissues; it behaves like the most malignant types 
 of sarcoma, giving early venous metastasis, especially to the lungs 
 (78 per cent.) and vagina (54 per cent.) (l)orland). Vaginal growths 
 may be the only evidences of the disease. The chief symptoms resemble 
 those of uterine carcinoma, namely bleeding, and watery leucorrhea. 
 The proper treatment is pan-hysterectomy, if the diagnosis is made 
 
1112 
 
 SURGERY OF THE FEMALE dENITALS 
 
 before distant metastases occur. Removal of vaginal growths in 
 cases where the uterus appears free from the disease, has occasionally 
 proved successful. 
 
 Fig. 1032.- 
 
 -Carcinoma of vulva; age forty-five years; duration eight months. 
 Pennsylvania Hospital. 
 
 Carcinoma of the Vulva is not very rare (Fig. 1032). Extension 
 occurs to the inguinal lymph nodes, and radical operation requires 
 the extirpation of these on both sides, the technique being similar 
 to that adopted in cases of carcinoma of the external genitals of the 
 male. 
 
iM)i:.\. 
 
 Ahi)()Mi;.\, gunshot wounds, 191 
 treatment, 845 
 injuries, 840 
 
 operation, 842 
 operations, 818 
 stab wounds, 844 
 Abdominal incisions, 818 
 
 operation, after-treatment, 825 
 preparation of jjatient, 823 
 technique, 823 
 section, 818 
 surgery, 802 
 tumors, diagnosis, 953 
 wall, contusion, 840 
 rupture, 840 
 Ablation of breast, 721 
 Abortion, tubal, 1090 
 Abrasions, 159 
 Abscess, 26, 47 
 acute, 47 
 
 treatment, 50 
 
 Hilton's method, 51, G75 
 alveolar, 657 
 appendicular, 858 
 
 treatment, 860 
 axillary, 729 
 Bezold's, 631 
 bone, 437 
 brain, 579 
 Brodie's, 437 
 chronic, 47 
 cold, 47, 79 
 
 treatment, 483 
 digital, 279 . 
 gluteal, 607 
 ihac, 607, 813 
 ischiorectal, 607, 903 
 liver, 936 
 lumbar, 607 
 lung, 748 
 mammary-, 700 
 
 chronic, 701 
 metastatic, 73 
 neck, 675 
 ovary, 1078 
 palmar, 279 
 pancreas, 946 
 pelvic, 813, 1077, 1096 
 
 extraperitoneal incision, 109(5 
 vaginal puncture, 1096 
 l)elvirectal, 904 
 
 Abscess, peri-anal, 903 
 
 pcrinei)iMic, 977 
 
 ])erit()nsillai-, (563 
 
 j)eri-urethral, 1027 
 
 phlegmonous, 47 
 
 pointing, 48 
 
 prostate, 1028 
 
 psoas, 607 
 
 residual, 805 
 
 peritoneal, 813 
 
 retropharyngeal, (506 
 
 scrofulous, 47 
 
 secondary, 73 
 
 spleen, 955 
 
 subcranial, 578 
 
 submammary, 702 
 
 subpectoral, 730 
 
 subphrenic, 813 
 
 subscapular, 731 
 
 tongue, 647 
 
 tubo-ovarian, 1077 
 
 vulvo-vaginal, 1071 
 Acapnia, 172 
 Achillodynia, 267 
 Achondroplasia, 417 
 Acne hyper trophica, 620 
 Acromegaly, 424 
 
 Acromioclavicular dislocation, 394 
 Actinomycosis, 84 
 Acupressure, 229 
 Acupuncture, 142 
 Adamantinoma, 112 
 Adenitis, 269 
 
 cervical, 674 
 Adenocarcinoma, 125 
 Adenoma, 119 
 
 of breast, 713 
 
 of rectum, 913 
 •Adenomatosis, 119 
 Adenomyoma of uterus, 1105 
 Adenosarcoma, 106 
 Adherent prepuce, 1046 
 Adhesions, peritoneal, 814 
 Ainhum, 64 
 Air-hunger, 227 
 
 Air passages, foreign bodies, 665 
 operations, 668 
 surgery, 6(35 
 
 sinuses, operations, 655 
 Albert-Lembert suture, 829 
 Albert's disease, 267 
 Albumosuria (Bence-Jones), 113 
 Alexander's operation, 1086 
 
1114 
 
 INDEX 
 
 Alexins, 23 
 
 Alimentary glycosuria, 'J4S 
 Allis's sign, 364 
 Alveolar abscess, 657 
 
 border, tumors, 660 
 Amebic dysentery, S95 
 Amicrobic meningitis, 579 
 Amputating knives, 195 
 Amputations, 192 
 
 ankle-joint, 211 
 
 arm, 207 
 
 Ashhurst's, 212 
 
 Billroth's, 216 
 
 breast, 710 
 
 Chopart's, 211 
 
 c'inematoplastic, 202 
 
 circular method, 197 
 
 conditions requiring, 192 
 
 dressing, 196 
 
 elbow, 207 
 
 elliptical method, 199 
 
 fingers, 205 
 
 flap method, 199 
 
 foot, 210 
 
 forearm, 206 
 
 Gritti's, 213 
 
 Guthrie's, 214 
 
 Hancock's, 214 
 
 hand, 205 
 
 Hey's, 210 
 
 hip-joint, 214 
 
 instruments, 192 
 
 interilioabdominal, 216 
 
 intermediate, 203 
 
 interscapulo-thoracic, 210 
 
 knee-joint, 213 
 
 Larrey's, 215 
 
 Lee's, 212 
 
 leg, 212 
 
 Lisfranc's, 210 
 
 medio-tarsal, 211 
 
 metacarpal, 203 
 
 methods, 197 
 
 modified circular method, 199 
 
 mortality, 203 
 
 multiple, 200 
 
 operative procedure, 195 
 
 oval method, 199 
 
 penis, 1050 
 
 Pirogoff's, 211 
 
 primary, 203 
 
 secondary, 203 
 
 Sedillot's, 212 
 
 Senn's, 215 
 
 shoulder-joint, 207 
 
 Skey's, 210 
 
 special, 205 
 
 subastragalar, 211 
 
 supracondylar, 213 
 
 Syme's, 211 
 
 Textor's, 211 
 
 thigh, 213 
 
 transcondylar, 213 
 
 traumatic, 192 
 
 wrist-joint, 206 
 Anaplasty, 225 
 
 Anastomosis, intestinal, 832 
 end-to-end, 833 
 lateral, 834 
 Murphy button, 839 
 
 nerve, 286 
 Anatomical tubercle, 76 
 Anel's ligation, 254 
 Anemia, splenic, 955 
 Anesthesia, 148 
 
 accidents, 151 
 
 chloroform, 152 
 
 ether, 149 
 
 ethyl chloride, 152 
 
 general, 148 
 
 administration, 153 
 choice, 152 
 
 in head operations, 153 
 
 infiltration, 156 
 
 in intrathoracic operations, 153 
 
 intratracheal insufflation, 154 
 
 local, 155 
 
 in neck operations, 153 
 
 nerve blocking, 157 
 
 nitrous oxide, 152 
 
 primary, 150 
 
 spinal, 157 
 
 vein, 158 
 Anesthetics, 148 
 Aneurysm, 247 
 
 by anastomosis, 247 
 
 Anel's ligation, 254 
 
 bone, 446 
 
 Brasdor's ligation, 255 
 
 cirsoid, 247 
 
 classification, 249 
 
 dissecting, 249 
 
 electrolysis, 256 
 
 extirpation of sac, 256 
 
 false, 248 
 
 osteoid, 113, 446 
 
 filipuncture, 256 
 
 Hunter's ligation, 254 
 
 ligation, 254 
 
 Matas's operation, 257 
 
 racemose, 247 
 
 saccular, 249 
 
 traumatic, 233, 247 
 
 treatment, 253 
 
 non-operative, 253 
 operative, 253 
 
 true, 248 
 
 tubular, 249 
 
 varicose, 235 
 
 v(Mi()Us, 233 
 
 \\'ar(lrop's ligation, 255 
 
 wiring, 256 
 Aneurysmal bruit, 252 
 
 varix, 235 
 Aneurysmoplasty, 258 
 Angeioleucitis, 268 
 Angeioma. See Heinangeioma 
 
 of breast, 713 
 Angeiotripsy, 229 
 Angina Ludovici, 645 
 Ankle dislocation, 413 
 
 tuberculosis, 500 
 
fXDKX 
 
 HIT) 
 
 Aiikli'-joiiit amimtatioii, "JII 
 Ankylosis, 4(57 
 
 ficatinciit, KIT 
 
 tul)('rculou.s, 4S7 
 Aiioci-iissoriiitioii, 14S 
 Aiilillcxioii uteri, lONd 
 Alltel liuracic csopliaKO-jejtiiio-fiustro.s- 
 
 loiny, (')96 
 Anteversion uteri, 1086 
 Anthrtix, 87 
 
 treatment, 89 
 Aiitihacteriul sera, 45 
 Antisepsis, 3(1, 131) 
 Antiseptic nietliods, 141 
 Antiseptics, 31) 
 Antitoxic sera, 4.') 
 Antitoxins, 23 
 Antylkis, operation of, 2").') 
 Anuria, calculous, 981 
 Anus, carcinoma, 913 
 
 false, formation of, 914 
 
 fissure, 905 
 
 surgery, 900 
 Apoi)lexy, 576 
 Appendicitis, 848 
 
 acute, 851 
 
 causes, 850 
 
 chronic, 863 
 
 complications, 857 
 
 diagnosis, 852 
 
 gangrenous, 861 
 
 obliterans, 849 
 
 operation, 854 
 
 pathogenesis, 848 
 
 peritonitis, 862 
 
 simple phlegmonous, 849 
 
 symptoms, 851 
 
 treatment, 854 
 
 ulcerative, 849 
 Appendicostomy, 896 
 Appendicular abscess, 858 
 
 treatment, 860 
 Appendix, carcinoma, 864 
 
 coprolith, 850 
 
 cyst, 850 
 
 empyema, 850 
 
 fecal conci'etion, 850 
 
 foreign bodies, 850 
 
 intussusception, 864 
 
 removal, 855 
 
 stricture, 850 
 
 surgery, 848 
 
 tuberculosis, 864 
 Arm, amputation, 207 
 Arrow-wounds, 170 
 Arsenic poisoning, bones in, 659 
 Arterial embolism, 242 
 
 thrombosis, 241 
 
 varix, 247 
 Arteriectasis, 248 
 Arteries, ligation, 230 
 methods, 231 
 rules for, 230 
 Arteriosclerosis, 241 
 Arteriovenous wounfls, 235 
 Arteritis, 241 
 
 Arthreclomy, 486 
 Arthritis, 4(V2 
 
 acute, of infants, 4(>4 
 rheumatic, 473 
 
 atroi)liic, 452 
 
 crypt ogcnous, 473 
 
 deformans, 452 
 
 gonococcic, 471 
 
 hypertrophic, 45(i 
 
 metastatic, 473 
 
 nodosa, 452 
 
 pneumococcic, 471 
 
 rheumatoid, 452 
 
 senil(>, 456 
 
 subpycmic, 473 
 
 sy|)hilitic, 503 
 
 tuberculous, 476 
 
 operation in, 486 
 
 tyi)hoid, 472 
 
 villous, 462 
 Arthrodesis, 528 
 Arthrolysis, 468 
 Arthroplastj', 471 
 Ascites, 940 
 Asepsis, 36, 139 
 Aseptic fever, 70 
 
 methods, 141 
 Ashhurst's amputation, 212 
 
 excision of knee, 469 
 Aspiration, 147 
 Astragalectomy, 521 
 Astragalus, dislocation, 414 
 
 fracture, 383 
 Auditory canal, furuncle, 628 
 Auricle, prominence of, 629 
 
 supernumerary, 629 
 Autotransfusion, 175 
 Axillary abscess, 729 
 
 infusion, 144 
 Azotorrhea, 947 
 
 B 
 
 Bacillary dj'sentery^ 895 
 Bacteria in inflammation, 18 
 pathogenic, 18 
 pyogenic, 28 
 saprophytic, 19 
 toxins, 19 
 Bacteriemia, 70 
 Bacteriolysins, 23 
 Bacteriuria, 964 
 Balanitis, 1048 
 Balano-posthitis, 1048 
 Bandage, figure-of-eight, 135 
 many-tailed, 135 
 plaster of Paris, 137 
 recurrent, 135 
 of Scultetus, 135 
 spiral, 135 
 
 reversed, 135 
 T-, 135 
 varieties, 135 
 Bandaging, 133 
 Banti's disease, 955 
 
1110 
 
 INDEX 
 
 Bartholin's gland, cyst of, 1072 
 Bartholinitis, 1071 
 Barton's fracture, 355 
 Basedow's disease, 688 
 Bassini's operation, 787 
 Bayonet wounds, 170 
 Bazin's disease, 264 
 Beck's bismuth paste, 484 
 
 operation, 1044 
 Bod-sore, 62 
 Bezold's abscess, 631 
 Bier's hyperemia, 40 
 Bile-ducts, carcinoma of, 942 
 
 infections, 919 
 
 operations, 928 
 
 surgery, 919 
 Biliary calculus, formation of, 919 
 
 colic, 924 
 
 fistula, post-operative, 928 
 
 sand, 922 
 Billroth's amputation, 216 
 
 gastrectomy, 881 
 
 powder, 219 
 Birth injuries, 1081 
 "Birth-mark," 244 
 Bismuth paste, 484 
 Bistoury, 49 
 Bites, 170 
 Bladder, calculus in, 966 
 
 carcinoma, 966 
 
 diverticula, 965 
 
 exstrophy, 962 
 
 foreign bodies, 971 
 
 injuries, 971 
 
 irrigation, 964 
 
 papilloma, 966 
 
 post-prostatic pouch, 1031 
 
 rupture, 971 
 
 surgerj-, 958 
 
 tuberculosis, 965 
 
 tumors, 966 
 Blank cartridge wounds, 186 
 Blastoma, 104 
 Blastomatoid growths, 107 
 Blastomycosis, 86 
 Blood-vascular system, diseases, 237 
 
 surgery, 227 
 Bloodvessels, gunshot wounds, 186 
 
 subcutaneous injuries, 233 
 
 suture of, 234 
 
 wounds, 233 
 Boas's area, 924 
 Boil, 261 
 Bone abscess, 437 
 
 aneurysm, 446 
 
 atrophj', 416 
 
 carcinoma, 450 
 
 caries, 431 
 
 congenital absence, 504 
 
 cysts, 445 
 
 diseases, 416 
 
 felon, 280 
 
 fibromas, 445 
 
 gunshot wounds, 186 
 
 infection, 425 
 
 lacunar resorption, 416 
 
 I Bone necrosis, 431 
 
 osteomyelitis, 426 
 Paget's disease, 423 
 sarcoma, 446 
 syphilis, 440 
 transplantation, 504 
 tuberculosis, 437 
 tumors, 443 
 wax, 435 
 Bottini operation, 1036 
 "Bottle operation," 1060 
 Bougie a boule, 1015 
 Bougies, 1015 
 
 filiform, 1015 
 Braces, 611 
 Bradford frame, 482 
 Brain abscess, 579 
 
 treatment, 581 
 compression, 571 
 concussion, 569 
 contusion, 569 
 cysts, 582 
 endothelioma, 581 
 sarcoma, 582 
 surgical affections, 567 
 syphiloma, 581 
 tuberculoma, 581 
 tumor, 581 
 
 decompressive operat ion, 
 
 589 
 treatment, 585 
 Branchial cysts, 682 
 Branchiogenic carcinoma, 683 
 Brasdor's ligation, 255 
 Breast, ablation of, 721 
 abscess, 701 
 adenoma, 713 
 adeno-sarcoma, 712 
 amputation, 710 
 angeioma, 713 
 caked, 700 
 cancer cyst, 720 
 carcinoma, 714 
 
 cauterization, 726 
 extension, 720 
 inoperable, 725 
 medullar}', 719 
 oophorectomy, 726 
 operation, radical, 721 
 
 end-results, 725 
 recurrence, 725 
 scirrhous, 715 
 simplex, 719 
 congenital anomalies, 699 
 cystudcnoma, 712 
 cj-stadenomatosis, 707 
 cystic disease, 707 
 cystosarcoma phyllodes, 712 
 enchondroma, 713 
 endothelioma, 713 
 fibro-adenoma, 711 
 fibro-adenomatosis, 706 
 fibrocystadenoma, 712 
 gumma, 704 
 hydatid disease, 712 
 hypertrophy, idiopathic, 706 
 
INDEX 
 
 1117 
 
 lircast, hypcrtniijliy, senile ii.iKMicliyiiiii- 
 luiis, 707 
 
 involution, 707 
 
 irritable t Minor, 702 
 
 lil)onia, 71.'5 
 
 myxoma, 71 1 
 
 neuralfiia, 702 
 
 l)a|)illary cystadenoma, 712 
 
 plastic resecition, 711 
 
 sarcoma, 713 
 
 scirrhus, 715 
 
 sero-cystic sarcoma, 712 
 
 surgery, 699 
 
 syphilis, 704 
 
 tuberculosis, 704 
 
 tumors, 705 
 benign, 710 
 malignant, 713 
 Brisemeiit, force, 468 
 Broad ligament cyst, 1099 
 Brodie's abscess, 437 
 Bronchiectasis, 749 
 Bronchoscopy, 666 
 Brvant's line, 364 
 Bubo, 269 
 
 chancroidal, 1006 
 
 parotid, 624 
 
 syphilitic, 992 
 Bubon d'emblee, 269 
 Bubonocele, 779 
 Budih's sign, 701 
 Bulbar symptoms, 572 
 Bullet wounds, 183 
 Bunion, 259 
 Burns, 217 
 
 duodenal ulceration, 218 
 
 electric, 222 
 
 treatment, 219 
 
 wounds, 266 
 
 a:-ray, 222 
 Bursitis, 267 
 
 Cachexia in malignant growths, 103 
 
 thyTeopriva, 688 
 Caked breast, 700 
 Calcaneiun, fracture, 383 
 Calculous anuria, 981 
 Calculus, biliary, formation of, 919 
 varieties, 922 
 
 lacteal, 704 
 
 pancreatic, 949 
 
 preputial, 1048 
 
 renal, 977 
 
 salivary, 627 
 
 ureteral, 981 
 
 urinarj', formation of, 977 
 
 vesical, 966 
 Callositas, 259 
 Callous ulcer, 55 
 Callus, 304 
 
 Cammidge reaction, 948 
 Cancer cyst of breast, 720 
 
 Caiicrum oris, 63 
 Capillar}' nevi, 244 
 Caput obstipum, 537 
 
 succedaneum, 551 
 Carbolic acid gangrene, 60 
 Carbuncle, 2()1 
 
 of lip, 641 
 Carcinoma, 1 19, 123 
 
 anus, 913 
 
 ajjpendix, 864 
 
 l)asal-celled, 123 
 
 bile-ducts, 942 
 
 bladder, 966 
 
 bone, 450 
 
 breast, 714 
 
 cauterization, 726 
 extension, 720 
 inoperable, 725 
 operation, radical, 721 
 
 end-results, 725 
 recurrence, 725 
 
 cecum, 895 
 
 cervix, 1109 
 
 colunmar-celled, 125 
 
 cylindrical-celled, 125 
 
 encephaloid, 126 
 
 epiblastic, 119 
 
 esophagus, 698 
 
 gall-bladder, 942 
 
 glandular, 125 
 
 hypoblastic, 119 
 
 jaw, 660 
 
 kidney, 983 
 
 larymx, 668 
 
 liver, 941 
 
 lymph nodes, 273 
 
 medullary, 125 
 
 pancreas, 950 
 
 penis, 1049 
 
 permeation, 120 
 
 prostate, 1042 
 
 rectum, 913 
 
 scirrhous, 125 
 
 simplex, 126 
 
 solid-celled, 125 
 
 squamous-celled, 121 
 
 stomach, 873 
 
 thyroid, 692 
 
 tongue, 649 
 
 tonsil, 664 
 
 treatment, 127 
 
 uterus, 1109 
 
 vulva, 1112 
 Cardiolysis, 237 
 Caries of ribs, 731 
 
 sicca, 477 
 
 of skull, 429 
 Carotid gland, tumors of, 680 
 Carpus, dislocation, 404 
 
 fracture, 359 
 Castration, 1056 
 Catarrhal jaundice, 921 
 Catheter, double-elbowed, 1034 
 
 introduction, 959 
 
 Mercier, 1034 
 Catheterism, 1034 
 
1118 
 
 IXDEX 
 
 Catheters, 958 
 Cauterization, 142 
 Cavernous anfjeiomas, 245 
 
 sinus thrombosis, 577 
 Cecal hernia, 785 
 Cecostomj', 896 
 Cecum, carcinoma, 895 
 
 mobile, 898 
 Cellulitis, 66 
 
 pelvic, 1094 
 Cephalhematoma, 551 
 Cephalocele, 553 
 Cerebral palsies, 530 
 Cerebritis, 579 
 Cervical ribs, 539 
 Cervix, carcinoma, 1109 
 
 laceration, 1081 
 
 stenosis, 1070 
 Chancre, 83, 989 
 
 Hunterian, 83 
 
 mixed, 991 
 
 superficial erosion, 83 
 
 of tongue, 649 
 Chancroid, 1005 
 
 treatment, 1007 
 Chancroidal bubo, 1006 
 
 treatment, 1008 
 Charbon, 87 
 Charcot's intermittent fever, 926 
 
 joint, 460 
 Chauffeur's fracture, 355 
 Cheeks, epithelioma, 624 
 
 keratosis senilis, 622 
 
 lupus, 624 
 
 plastic operations, 623 
 
 rodent ulcer, 624 
 
 seborrheic patch, 622 
 
 surgerv, 622 
 Cheloid, 109 
 Chemotaxis, negative, 21 
 
 positive, 21 
 Chest wall, injuries, 726 
 
 malformations, 726 
 
 rachitic deformities, 726 
 
 surgerv, 699 
 Chilblain, 222 
 Chloroform anesthesia, 152 
 Chloroma, 114 
 Cholangeitis, 921 
 Cholecystectomy, 931 
 Cholecystendysis, 930 
 Cholecystenterostomj', 934 
 Cholecystoduodenostomy, 934 
 Cholecysto-gastrostomv, 934 
 Cholecystitis, 919 
 
 calculous, 925 
 
 chronic, 920 
 
 treatment, 921 
 Choledocho-enterostomy, 928 
 Choledochostomy, 932 
 Choledochotomj', 932 
 
 retroduodenal, 933 
 
 transduodenal, 934 
 Cholelithiasis, 922 
 
 Murphy's test, 924 
 
 simple, 923 
 
 Cholelithiasis, treatment, 926 
 Cholemia, 926 
 Cholesteatoma, 129 
 Cholesterin, gall-bladder, 922 
 Chondrectomy, 748 
 Chondroma, ilO 
 Chondrosarcoma, 116 
 Chopart's amputation, 211 
 Chordoma, 114 
 Chorio-epithelioma, 106, 1111 
 Chromoureteroscopj', 961 
 Chvle duct, wounds of, 268 
 Chylothorax, 268, 738 
 Chylous ascites, 268 
 Cicatrization, 30, 53 
 Cigarette drain, 52 
 Cinematoplastic amputation, 202 
 Circumcision, 1046 
 Cirrhosis, liver, 940 
 
 of stomach, 872 
 Cirsoid aneurvsm, 247 
 "Clacking jaw," 392 
 Clavicle, dislocation, 392 
 
 fracture, 326 
 Clavus, 259 
 Cleft palate, 634, 638 
 operation, 638 
 
 scrotum, 1043 
 Cloaca^, 426 
 Cloquet's hernia, 794 
 Club foot, 515 
 
 hands, 515 
 Cocain anesthesia, 155 
 Coccj'godynia, 325 
 Coccyx, fracture, 325 
 Cock's operation, 1025 
 Coin-catcher, 694 
 Cold abscess, 79 
 
 effects of, 221 
 Coley's fluid, 117 
 Colic, renal, 979 
 Colitis, 895 
 Collapse, 172 
 CoUes's fracture, 351 
 
 law, 998 
 Colon, surger.y of, 895 
 Colostomv, 915 
 Colpocele, 1082 
 
 anterior, 1088 
 Colpo-perineorrhaphy, 1083 
 Colporrhaphy, posterior, 1083 
 Common duct, obstruction, 928 
 
 stone in, 925 
 Compression of brain, 571 
 
 treatment, 574 
 Concussion of brain, 569 
 
 of spinal cord, 594 
 Condylomata lata, 995 
 Congenital absence of bone, 504 
 
 deformities, 504 
 
 megacolon, 900 
 
 talipes, 515 
 Congestion, 20 
 Constipation, 899 
 Contracture, palmar fascia, 542 
 
 Volkmann's, 540 
 
IXDI-X 
 
 111!) 
 
 Contniftun's of imisclcs, 270 
 Contused wounds, 1()7 
 Contusion, 151) 
 
 ahdoniiniil wall, HW 
 l)rain, ")t')9 
 joints, 385 
 nerves, 2S2 
 scalp, o")! 
 Cooper's hernia, 7!)4 
 Corn, 259 
 
 Cornu eutanoum, 2(i() 
 Corona veneris, !)i)5 
 Corpus luteuni eyst, H)i>7 
 Corset liver, 985 
 Costo-t ransversectoniy, 1 4 
 Countw-irritation, 142 
 Courvoisier's law, 926 
 Coxa valga, 540 
 
 vara, 543 
 Coxalgia, 4S8 
 
 Cranial defects, repair, 567 
 Craniocerebral topography, 567 
 Craniotomy, osteoplastic, 5S6 
 Cricothyrotoniy, 670 
 Critical discharges, 31 
 Crural hernia, 793 
 Crushed limbs, treatment, 204 
 Crutch-palsy, 282 
 Cryoscopy, 902 
 Cryptogenous arthritis, 473 
 Cryptorchidism, 1050 
 Cubitus valgus, 346, 540 
 
 varus, 346, 540 
 Cuneiform tarsectomy, 521 
 Cushing's decompressive operation, 
 
 suture, 831 
 Cut-throat, 673 
 C}'lindroma, 128 
 Cyst or cysts, 129 
 
 appendix, 850 
 
 Bartholin's gland, 1072 
 
 bone, 445 
 
 brain, 582 
 
 branchial, 682 
 
 broad ligament, 1099 
 
 corpus luteum, 1097 
 
 dentigerous, 112, 661 
 
 dermoid, of ovary, 1101 
 of scalp, 553 
 
 extravasation, 129 
 
 Graafian follicle, 1097 
 
 hydatid, 131 
 
 kidney, 984 
 
 lip, 640 
 
 liver, echinococcus, 938 
 
 mesenteric, 895 
 
 omental, 895 
 
 ovary, 1097 
 
 dermoid, 1101 
 
 pancreas, 952 
 
 parasitic, 131 
 
 parovarian, 1099 
 
 pilo-nidal, 130, 266 
 
 retention, 129 • 
 
 sebaceous, 265 
 of scalp, 553 
 
 590 
 
 Cyst or cj'sts, sequestration, 130 
 
 spleen, 955 
 
 thyro-glossal, 6S1 
 
 tul)o-()varian, 1098 
 
 urachal, 963 
 Clystadeno-carcinoma, 1 25 
 Cyst adenoma, 119 
 
 breast, 707, 712 
 
 ovary, 1098 
 
 ])apilliferum, 119 
 Cystadenomatosis of breast, 707 
 Cystic duct, stone in, 925 
 Cystitis, 903 
 Cystocelc, 1082, 1088 
 
 operation, 1088 
 Cystoscope, 900 
 Cystotomy, suprapubic, 970 
 Czerny's suture, 829 
 
 Winkelschnitt, 928 
 
 Dactylitis, syphilitic, 441 
 
 tuberculous, 439 
 Dance's sign, 886 
 "Dangle-foot," 528 
 Deaver's incision, 820 
 Deciduoma malignum, 106, 1111 
 Decompression, 574 
 Decompressive operation, 589 
 Decortication of lung, 745 
 Decubitus, 62 
 Deformities, congenital, 504 
 
 of head, 537 
 
 of neck, 537 
 
 paralytic, 521 
 Delirium cordis, 690 
 
 traumatic, 173 
 
 tremens, 174 
 Demarquay's operation, 1018 
 Dentigerous cyst, 112, 661 
 Dermatitis, x-ray, 222 
 Desmoids, 277 
 Determination of l)lood, 20 
 Diacondylar fractures, 341 
 Diapedesis, 20 
 Diaphragm, eventration, 751 
 
 gunshot wounds, 750 
 
 hernia, 751 
 
 rupture, 750 
 
 stab wounds, 749 
 
 surgery, 749 
 Dietls's crises, 972 
 Digital abscess, 279 
 Dilatation of esophagus, 697 
 
 of stomach, acute, 869 
 secondary, 870 
 Discission of pleura, 746 
 Disinfection, iodin, 141 
 Dislocated kidney, 973 
 
 spleen, 955 
 Dislocation of acromio-clavicular joint, 
 393 
 
 ankle, 413 
 
1120 
 
 IXDEX 
 
 Dislocation of astragalus, 414 
 
 carpal bones, 404 
 
 clavicle, 392 
 
 elbow, 399 
 
 fingers, 40.5 
 
 hip, 405 
 
 congenital, 507 
 
 humerus, 394 
 
 knee, 412 
 
 congenital, 515 
 
 mandible, 391 
 
 mediotarsal joint, 415 
 
 metacarpus, 404 
 
 metatarsus, 415 
 
 nerves, 283 
 
 patella, 279 
 
 phalanges, 404 
 
 radiocarpal joint, 403 
 
 radius, head of, 402 
 
 sacro-iliac joints, 405 
 
 scapula, 394 
 
 shoulder, 394 
 
 congenital, 513 
 
 spine, 594 
 
 sternoclavicular joint, 392 
 
 tarsus, 414 
 
 tendons, 278 
 
 tibiotarsal joint, 413 
 
 vertebrae, 594 
 
 WTist, 403 
 Dislocations, 387 
 
 causes, 388 
 
 complicated, 391 
 
 compound, 390 
 
 congenital, 507 
 
 consecutive, 388 
 
 old, 391 
 
 pathological, 388 
 
 primitive, 388 
 
 recurrent, 391 
 
 reduction, 390 
 
 special, 391 
 
 spontaneous, 388 
 
 subastragalar, 415 
 
 traumatic, 388 
 
 treatment, 390 
 Dissecting aneurj'sm, 249 
 Diverticulum of bladder, 965 
 
 of esophagus, 697 
 Diverticulitis, sigmoid, 897 
 Drainage tube, 51 
 Dressing forceps, 49 
 
 wounds, 166 
 Dudlej^'s operation, 1070 
 Duodenum, ulcer, 864 
 in burns, 218 
 chronic, 865 
 hemorrhage, 868 
 perforation, 867 
 treatment, 866 
 Dupuytren's contracture, 542 
 
 suture, 831 
 Dysentery, amebic, 895 
 
 bacillary, 895 
 Dystrophies of bone, 416 
 
 of joints, 451 
 
 E 
 
 Ear, foreign bodies in, 628 
 
 surger.y of, 628 
 Ear-ache, 630 
 Ecchondroma, 110 
 Ecchymosis, 159 
 Echinococcus cyst of liver, 938 
 Eck's fistula, 941 
 Ectopic gestation, 1090 
 Edema of glottis, 668 
 Edematous ulcer, 54 
 Elbow, amputation, 207 
 
 dislocation, 399 
 
 excision, 470 
 
 tuberculosis, 501' 
 Electric current injuries, 217 
 Elephantiasis Arabum, 271 
 
 of scrotum, 1062 
 Embolism, 73, 237 
 
 arterial, 241 
 
 mesenteric, 890 
 
 post-operative, 178 
 
 pulmonary, 178, 241 
 
 retrograde, 73 
 Embolus, 73 
 Embr}'oma, 106 
 Empyema of appendix, 850 
 
 articuli, 462 
 
 gall-bladder, 920 
 
 necessitatis, 740 
 
 thoracis, 739 
 
 bilateral, 744 
 Emphysema, pulmonary, 748 
 
 surgical, 728 
 Emphysematous gangrene, 65 
 Encephalitis, 579 
 Encephalocele, 553 
 Encephalocystocele, 553 
 Enchondroma, 110 
 
 of breast, 713 
 Endo-aneurysmorrhaph}', 257 
 Endocervicitis, 1073 
 Endometritis, 1073 
 
 putrid, 1093 
 
 septic, 1094 
 Endosteoma, 111 
 Endostosis, 112 
 Endothelioma, 127 
 
 of brain, 581 
 
 of breast, 713 
 Endotoxins, bacterial, 19 
 End-to-end anastomosis, 833 
 Enostosis, 112 
 Enterocele, 755 
 Entero-epiplocele, 755 
 Enterorrhaphy, circular, 832 
 Epicondylitis, 342 
 
 Epidemic cerebrospinal meningitis, 57J 
 Epididymitis, 1052 
 Epididymo-orchitis, 1052 
 Epididymo-vasostomy, 1053 
 Epigastric hernia, 771 
 Epignathus, 106 
 Epilepsy, focal, 590 
 
 Jacksonian, 590 
 
LXhKX 
 
 l']|)i|)l()C('l(', 7.").") 
 Epiphyseal .separation, '-".Id 
 I'lpipliysitis, acute, \'M\ 
 I'lpispailias, 101") 
 I'lpistaxis, (il!) 
 lOpillielioiiia, 121 
 
 of cliecks, ()24 
 
 deep-seated, 121 
 
 of lip, on 
 
 pai)illarv, 12;i 
 
 pearly Ixxlies, 122 
 
 of scalp, rt')'A 
 
 superficial, 123 
 I'lpitrochlea, fracture, 344 
 KlJiilis, ()()() 
 Mrasioii of joiut.s, 4S6 
 I'j-etliistic shock, 173 
 Erysipelas, 67 
 
 phlegmonous, 09 
 
 treat lueut, (i!) 
 iM-ytheina induratuiu, 2()4 
 
 nodosum, 2G4 
 Ksmarch anemia, 433 
 Esmarch's elastic band, 194 
 Esophagotoniy, external, ()94 
 
 internal, 695 
 Esophagus, carcinoma, 098 
 
 dilatation, 697 
 
 diverticulum, 697 
 
 foreign bodies, 693 
 
 imperforation, 697 
 
 stricture, 695 
 
 surgery, 693 
 Est lander's operation, 746 
 Ether anesthesia, 149 
 Ethmoidal disease, 655 
 Ethyl chloride anesthesia, 152 
 Eucain anesthesia, 155 
 Eventration of diaphragm, 751 
 Evidement, 436 
 Excision of elbow, 470 
 
 of hip, 497 
 
 of inferior maxilla, 662 
 
 of joints for ankylosis, 469 
 
 of knee, 469 
 
 of shoulder, 470 
 
 of superior maxilla, 662 
 
 of wrist, 470 
 Excoriation, 159 
 Exophthalmic goitre, 688 
 Exostoses, cartilaginous, 443 
 
 fibrous, 444 
 
 subungual, 444 
 Exostosis, 112 
 
 bursata, 445 
 Exploring needle, 4i) 
 Exstrophy of bladder, 962 
 Extradural hemorrhage, 574 
 Extra-uterine pregnancy, 1090 
 
 Facial hemiatrophy, 660 
 False anus, 831, 893, 914 
 Farcy, 89 
 71 
 
 l''at-eiul)olism, 178 
 
 necrosis, 944 
 Fecal fistula, 893 
 
 impaction, 88!) 
 Felon, 280 
 
 Female genitals, surgery of, 1064 
 Femoral hernia, 793 
 
 treatment, 795 
 Femur, fracture, 362 
 
 shaft of, fracture, 368 
 Fever, 70 
 
 asei)t ic, 70 
 
 surgical, 71 
 Fibrin, 24 
 Fibro-adenoma, 119 
 
 of breast, 711 
 Fibro-adenomatosis of breast, 706 
 Fibroid, 114 
 
 recurrent, 116 
 
 of uterus, 1102 
 
 treatment, 1106 
 Fibroma, 108 
 
 bone, 445 
 
 molluscum, 108 
 
 neck, 684 
 Fibromatosis nervorum, 114 
 Fibromyoma of uterus, 1102 
 Fibromyxoma, 109 
 Fibrosarcoma, 109, 116 
 Fibula, fracture of, 379 
 Filaria sanguinis hominis, 271 
 Filariasis, 271 
 Filiform bougies, 1015 
 Filipuncture in aneurysm, 256 
 P'ingers, amputation, 205 
 
 congenital contraction, 506 
 
 supernumerary, 505 
 
 webbed, 506 
 Finney's pyloroplasty, 879 
 Fissure of anus, 905 
 
 of nipple, 700 
 
 of Rolando, 568 
 Fistula, 48, 52 
 
 in ano, 904 
 
 biliary, 921 
 
 postoperative, 928 
 
 blind, 52 
 
 branchial, 682 
 
 Eck's, 941 
 
 gastro-colic, 891 
 
 genital, 1089 
 
 pancreatic, 946 
 
 pilo-nidal, 266 
 
 pleural, 744 
 
 recto-genital, 913 
 
 recto-urethral, 913 
 
 recto-urinary, 913 
 
 recto-uterine, 913, 1089 
 
 recto-vaginal, 913 
 
 salivary, 626 
 
 suprapubic, 103(5 
 
 thj-ro-glossal, 681 
 
 treatment, 52 
 
 umbilical, 891 
 
 urachal, 963 
 
 uretero-cervical, 1089 
 
1122 
 
 INDEX 
 
 Fistula, urinarv, 1027 
 
 vesico-utcrinc, 913, 10S9 
 
 vesico-vaginal, 913, 1089 
 F"ixed dressings, 137 
 Flat-foot, 547 
 Floating kidney, 973 
 Fluxion of blood, 20 
 Focal epilepsy, 590 
 
 symptoms, 572 
 Foot, amputations, 210 
 
 fracture, 3S2 
 Forearm, amputations, 206 
 
 fractures, 355 
 Foreign bodies in air pas.sages, 665 
 in appendix, 850 
 in bladder, 971 
 in ear, 628 
 in esophagus, 693 
 in nose, 620 
 in soft parts, 169 
 Fowler's position, 811 
 Fracture, acetabulum, 325 
 
 astragalus. 3S3 
 
 Barton's, 355 
 
 calcaneum, 383 
 
 carpus, 359 
 
 chauffeur's, 355 
 
 clavicle, 326 
 
 coccyx, 325 
 
 Colles', 351 
 
 elbow, 338 
 
 face bones, 320 
 
 femur, 362 
 shaft, 368 
 
 fibula, 379 
 
 forearm, 355 
 
 hip, 362 
 
 humerus, 331 
 shaft. 336 
 
 larvnx, 667 
 
 leg, 376 
 
 malar bone, 320 
 
 mandible, 321 
 
 maxilla, 321 
 
 metacarpus. 361 
 
 metatarsus, 384 
 
 by muscular action, 297 
 
 nasal bones, 320 
 
 olecranon, 348 
 
 patella, 372 
 
 jAalanges, 362, 384 
 
 r el vie bones, 323 
 
 Pott's, 380 
 
 radius, 350 
 
 ribs, 323 
 
 scapula, 330 
 
 skull, 557 
 
 spine. 594 
 
 sternum. 322 
 
 supracondylar, of humerus, 339 
 
 tarsus, 382 
 
 tibia, 376 
 
 trochanter, 368 
 
 uhia. 348 
 
 veitebrap, 594 
 
 zygoma, 320 
 
 Fractures, 294 
 
 after-care, 309 
 
 badly united, treatment, 315 
 
 callus, 304 
 
 causes, 297 
 
 classification, 294 
 
 comminuted, 294 
 
 complete, 294 
 
 complicated, 295 
 treatment, 312 
 
 compoimd, 294 
 
 treatment, 312 
 
 delayed union, 306 
 
 depressed, 296 
 
 diagnosis, 301 
 
 double, 294 
 
 green-stick, 294 
 
 gunshot, 186 
 
 impacted, 296 
 
 incomplete, 294 
 
 mechanism, 297 
 
 multiple, 295 
 
 pathological, 298 
 
 process of union, 303 
 
 ring, 559 
 
 simple, 294 
 
 treatment, 307 
 
 operative, 310 
 
 skiagraphy, 302 
 
 special, 319 
 
 spontaneous, 298 
 
 sprain, 298 
 
 symptoms, 298 
 
 treatment. 306 
 
 ununited, 306, 316 
 treatment, 317 
 Fragilitas ossium, 416 
 Frazier-Spiller operation, 292 
 Friar's balsam, 638 
 Frost-bite, 221 
 Fungus cerebri, 590 
 Fininel breast, 726 
 Furuncle, 261 
 
 auditory canal, 628 
 
 Galactocele, 703 
 Gall-bladder, carcinoma, 942 
 
 cholesterin, 922 
 
 em])vema, 920 
 
 hydrops, 920 
 
 infections, 919 
 
 operations, 928 
 
 perforation, 921 
 
 strawberry, 922 
 
 surgery, 919 
 (Jail-stones, formation of. 919 
 
 in coinnion duct, 925 
 
 in cystic duct. 925 
 
 in hei)atic duct, 926 
 
 migrated, 925 
 
 varieties, 922 
 Gait's trephine, 563 
 Ganglion, 281 
 
IXDKX 
 
 1123 
 
 (Janj^lion, fr;iss(>rian, oxtir|)ati()n ol", 1291 
 ( lanttrciic, oS 
 
 arterial occlusion, trcalnicnt, (i'J 
 
 causes, f)!* 
 
 (•arl)()lic acid, ()() 
 
 (liahet ic, treat itieiit, (il 
 
 dry, <)() 
 
 eiii])liyseiiiatoUS, (').") 
 
 i'oiidroyaiite, ().") 
 
 liospit.al, iV.i 
 
 line of demarcation, (id 
 oi separation, (iO 
 
 of lung, 748 
 
 moist, ()() 
 
 of pancreas, i)4() 
 
 .senile, 59 
 
 trout ment, 01 
 
 spreading, 65 
 
 symmetrical, 64 
 
 symptoms, 60 
 
 traumatic, 65 
 
 treatment, 61 
 
 varieties, 60 
 Caiigrenous stomatitis, 63 
 Gartncu-'s duct, 1099 
 Gasserian ganglion, extirpation of, 291 
 Gastrectomy, 881 
 
 Billroth's, 881 
 
 Hartmann's line, 874 
 
 partial, 881 
 
 subtotal, 884 
 
 total, 884 
 Gastric ulcer, 864 
 Gastro-anastomosis, 872 
 (Jastro-colic fistula, 891 
 Gastrogastrostomy, 872 
 Gastro-intestinal tract, rupture of, 842 
 Gastrojejunostomy, 879 
 Gastro'plasty, 87l" 
 ( lastrostomy, 877 
 Gastrotomy, 876 
 (Genital fistula, 1089 
 Genitalia, female, examination, 1065 
 (Jenitals, female, surgery of, 1064 
 
 male, surgery of, 1043 
 Gcrsuni's operation, 910 
 Gestation, ectopic, 1090 
 Glanders, 89 
 Gleet, 1011 
 Glioma, 114 
 
 brain, 581 
 (iliosarcoma, 116 
 Glossitis, 647 
 Glottis, edema of, 668 
 CJluteal abscess, 607 
 Goitre, 684 
 
 colloid, 685 
 cystic, ()86 
 diffuse, 685 
 exo])lithalmic, (588 
 nodular, ()86 
 operation, ()87 
 I)arenchymatous, 685 
 treatment, 687 
 Gonococcic joint infection, 471 
 urethritis, 1010 
 
 Gonorrheji, 1009 
 female, 1070 
 treatment, 101 I 
 
 abortive, 1012 
 
 autogenous vaccines, 101 I 
 
 prophylactic, 101 1 
 Gia.'iliaii follicle cyst, 1097 
 ( Iiamdation tissue, 26, 30 
 
 tuberculous, 79 
 ( iraiiulations, 30, 53 
 ( ii'amdouia, infectious, 19, 7() 
 (ii'aves's disease, 688 
 (iritti's amputation, 213 
 Gumma of breast, 704 
 of testicle, 1057 
 of tongue, 649 
 Ciummas, 84, 997 
 Gunshot wounds, 180 
 
 of alxlomen, 191, 844 
 
 of iilood vessels, 186 
 
 of bones, 18(i 
 
 of diaphragm, 750 
 
 of head, 188 
 
 of intestine, 845 
 
 of joints, 186 
 
 of liver, 847 
 
 of lungs, 189 
 
 of nerves, 186 
 
 of pancreas, 847 
 
 of spine, 189 
 
 of spleen, 847 
 
 of stomach, 846 
 
 of thorax, 189 
 Guthrie's amputation, 214 
 Gypsum, 137 
 
 Hallux valgus, 549 
 Halsted's suture, 831 
 Hammer toe, 549 
 Hancock's amputation of, 211 
 Hand, amjjutation, 205 
 Hare-lip, 634 
 
 double, 637 
 
 single, 635 
 Harrison's groove, 726 
 Hartmann's line for gastrectomy, 874 
 Head deformities, 553 
 
 gunshot injuries, 188 
 
 oi)erations, anesthetic, 153 
 
 surgery of, 551 
 Heart, foreign bodies in, 237 
 
 injuries, 236 
 
 massage, 237 
 
 ruj^ture, 236 
 
 wounds, 236 
 Heat, effects of, 217 
 
 prostration, post-operative, 179 
 Heberden's nodes, 456 
 Hecti(! fever, 75 
 Heliotherapy, 484 
 Hemangeio-endothelioma, 1 28 
 Hemangeioma, 244 
 Hemarthrosis, 387 
 
1124 
 
 INDEX 
 
 Hematocele, 1061 
 Heinatocolpos, 1069 
 Hematoma, 160, 233 
 
 auris, 629 
 Hematometra, 1069 
 Hematomyelia, 594 
 Hemiatrophy, facial, 660 
 Hemilaryngectomy, 672 
 Hemophilia, 227 
 Hemorrhage, 227 
 apparent, 227 
 arterial, 227 
 concealed, 227 
 (ionstitiitional signs, 227 
 extradural, 574 
 internal, 227 
 
 intestinal, in typhoid, 893 
 intracerebral, 576 
 intradural, 575 
 middle meningeal, 575 
 operative, 176 
 primary, 177 
 reactionary, 177 
 secondary, 177, 232 
 treatment, 232 
 subcranial, 574 
 subcutaneous, 227 
 treatment, 228 
 
 acupressure, 229 
 cold, 229 
 forcipressure, 229 
 heat, 229 
 ligation, 229 
 position, 228 
 l)ressure, 228 
 styptics, 229 
 torsion, 229 
 venous, 227 
 Hemorrhagic pancreatitis, 914 
 
 peritonitis, 805 
 Hemorrhoids, 906 
 
 treatment, 907 
 Hemothorax, 737 
 Hepatic duct, stone in, 926 
 Hepatico-enterostomy, 928 
 Hepaticus drainage, 933 
 Hepatitis, suppurative, 936 
 Hepatoptosis, 935 
 Hepatotomy, 937 
 Hermaphrodism, 1045 
 Herpes progenitalis, 1048 
 Hernia, 753 
 
 causes, 754 
 cecal, 785 
 cerebri, 590 
 classification, 770 
 of Cloquet, 794 
 of Cooper, 794 
 crural, 793 
 diai:)hragmatic, 751 
 cnterocele, 755 
 entero-epiplocele, 755 
 epigastric, 771 
 epiplocele, 755 
 femoral, 793 
 
 operation, 795 
 
 Hernia, femoral, rare forms, 794 
 strangulation, 799 
 treatment, 795 
 of Hesselbach, 794 
 incarcerated, 761 
 
 treatment, 761 
 incisional, 772 
 inHamcd, 760 
 inguinal, 779 
 
 complete, 783 
 direct, 792 
 
 treatment, 793 
 incomplete, 783 
 nomenclature, 779 
 oblique, 780 
 
 operation, 787 
 treatment, 785 
 properitoneal, 784 
 strangulation, 784 
 truss, 786 
 inguino-crural, 785 
 irreducible, 759 
 
 treatment, 760 
 ischiatic, 801 
 labial, 779 
 Laugier's, 794 
 Littre's, 755 
 lumbar, 779 
 lung, 736 
 muscle, 274 
 nomenclature, 754 
 obstructed, 760 
 obturator, 799 
 Partridge's, 794 
 pectineal, 794 
 perineal, 800 
 preperitoneal fat, 771 
 pudendal, 800 
 recurrence, 785 
 reducible, 756 
 
 treatment, 757 
 retrovascularis, 794 
 Richter's, 755 
 sac, 754 
 
 contents, 755 
 sigmoid, 785 
 sliding, 785 
 special, 770 
 strangulated, 761 
 operation, 766 
 taxis, 766 
 treatment, 765 
 suj)ravesical, 792 
 taxis, 766 
 of Tessier, 794 
 truss, 758 
 umbilical, 774 
 adult, 776 
 congenital, 774 
 infantile, 774 
 strangulated, 778 
 vaginal, 800 
 ventral, 772 
 Hesselbach's hernia, 794 
 Hey's amputation, 310 
 Hilton's method of opening abscesses, 675 
 
INDEX 
 
 112.5 
 
 Hip, central dislocation, 32.') 
 
 dislocation, 40.') 
 
 conficnital, .")n7 
 
 excision, 4*J7 
 
 fract>in', MVl 
 
 tnberculosis, 4S.S 
 Hip-joint amputation, 214 
 Hirschsprung's disease, 000 
 Hodgkin's di.sea.se, 114, 271 
 Hollow foot, .51.5 
 Horn, 260 
 
 Horse-shoe kidney, 072 
 Horslej's wax, .5SS 
 Hospital gangrene, (io 
 Hour-glass stomach, 871 
 " Hou.semaid's knee," 267 
 Hudson's trephine, 56.3 
 Humerus, dislocation, 394 
 
 fracture, 331 
 
 shaft, fracture, 336 
 Hunterian chancre, 83 
 Hunters ligation, 254 
 Hutchin.son's teeth, 1000 
 Hydatid cyst of liver, 938 
 
 di.sea.se of breast, 712 
 
 of Morgagni, 1099 
 Hydrarthrosis, intermittent, 466 
 Hydrencejihalocele, 553 
 Hydrocele, 105S 
 
 acquired, 1059 
 
 acute, 1053 
 
 of canal of Xuck, 1061 
 
 congenital, 1058 
 
 of the cord, 1060 
 
 encysted, of cord, 1061 
 of tunica, 1061 
 
 funicular, 1060 
 
 operation, 1060 
 
 treatment, 1060 
 
 vaginal, 1059 
 Hydrocephalus, 554 
 
 acquired, 554 
 
 congenital, 555 
 Hydronephrosis, 976 
 Hj'clrophobia, 96 
 
 furious, 97 
 
 jjaralj-tic, 97 
 
 Pasteur treatment, 99 
 Hvdrops articuli, 462 
 
 of gall-bladder, 920 
 Hydrorachis, 592 
 Hytlrosalpinx, 1077 
 Hydrothorax, 729 
 Hj-groma, 683 
 Hylomas, 106 
 
 Hyperemesis lactantium, 869 
 Hj'peremia, active, 20 
 
 passive, 20 
 Bier's, 40 
 Hypernephroma, 127, 983 
 Hjperostosis, 112 
 Hypertrophy of bone, 424 
 
 of prostate, 1029 
 Hyperthyroidism, 688 
 
 treatment, 690 
 Hypodermic injections, 143 
 
 Hyj)odermoclysis, 144 
 Hjpoleukocytosis, 31 
 Hypospadias, 1043 
 Hypothyroidism, 684, 688 
 Hysterectomy, abdominal, 1106 
 
 vaginal, 1108 
 Hysteropexy, 1086 
 
 Ichthyosis of tongue, 647 
 Idiopathic fragilitas o.ssium, 416 
 
 sijlenomegal}', 956 
 Ileus, 884 
 Iliac abscess, 607 
 Imperforate anus, 902 
 
 esophagus, 697 
 
 hymen, 106!) 
 
 rectum, 902 
 
 vulva, 1069 
 Incarcerated hernia, 761 
 Incised wounds, 160 
 Incision, abdominal, 818 
 closure, 821 
 
 Czerny's, 928 
 
 Davis's, 821, 854 
 
 Deayer's, 821 
 
 gridiron, 829 
 
 Kehr's, 928 
 
 kidnej', 985 
 
 McBurnev's, 820 
 
 :Mayo Robson's, 820, 928 
 
 muscle-splitting, 820 
 
 Sprengel's, 928 
 
 transverse, 821, 854, 928 
 Incisional hernia, 772 
 Indian rhinoplasty, 621 
 Indigo-carmine test, 961 
 Infantile paralj'sis, 521 
 Infants' arthritis, 464 
 Infectious granulomas, 19, 76 
 Infiltration anesthesia, 156 
 Inflammation, 17 
 
 alexins, 23 
 
 antitoxins, 23 
 
 bacteriolysins, 23 
 
 causes, 18 
 
 bacteria, 18 
 exciting, 18 
 predisposing, 18 
 toxins, 19 
 
 cellular infiltrate, 22 
 
 chronic, 35 
 
 cure, 37 
 
 diapedesis, 20 
 
 diseases resulting from, 47 
 
 extension, 27 
 
 fever, 70 
 
 fibrin, 24 
 
 fibroblasts, 22 
 
 leukocj-tes, 22 
 
 lymphization, 23 
 
 IjTnphocytes, 22 
 
 Ij-mphogenesis, 23 
 
 margination, 20 
 
U26 
 
 INDEX 
 
 Inflammation, mifrratiori, 20 
 modified forms, 70 
 nervous system, 27 
 l)atliology, 19 
 
 summary, 29 
 phlegmonous, 2(') 
 pyrexia, 70 
 regeneration, 30 
 repair, 29 
 resolution, 23 
 resulting affections, 70 
 subacute, 35 
 symptoms, 31 
 
 heat, 33 
 
 impaired function, 34 
 
 local, 32 
 
 modification of nutrition, 35 
 
 muscular rigidity, 34 
 
 pain, 33 
 
 referred, 33 
 
 redness, 32 
 
 swelling, 33 
 
 tenderness on pressure, 34 
 terminations, 27 
 treatment, 35 
 
 alteratives, 44 
 
 Bier's hyperemia, 40 
 
 cathartics, 42 
 
 cold, 37 
 
 compression, 40 
 
 constitutional, 41 
 
 counter-irritants, 39 
 
 diaphoretics, 43 
 
 diet, 41 
 
 diuretics, 43 
 
 douches, 39 
 
 drugs, 42 
 
 heat, 38 
 
 hygiene, 41 
 
 incision, 40 
 
 irrigation, 38 
 
 local, 37 
 
 bleeding, 39 
 
 massage, 41 
 
 narcotics, 39 
 
 operation, 40 
 
 position, 37 
 
 ])rophylaxis, 35 
 
 rest, 37 
 
 sedatives, 42 
 
 serum therapy, 44 
 
 stimulants, 43 
 
 stimulation of i)hagocytosis, 
 
 tonics, 44 
 
 vaccines, 44 
 
 venesection, 39 
 Inflammatory fever, 71 
 
 lymph, 24 
 Infusion, axillary, 144 
 intravenous, 145 
 Ingrowing toe-nail, 260 
 Inguinal hernia, 779 
 
 complete, 783 
 
 direct, 792 
 
 treatment, 793 
 
 incomplete, 783 
 
 44 
 
 Inguinal hernia, oblicjue, 780 
 j)r()peritoneal, 784 
 strangulation, 784 
 Inguino-('rural hernia, 785 
 Injuries, 159 
 
 general effec-ts, 172 
 local effects, 159 
 Insect-stings, 170 
 Intestinal anastomosis, 832 
 end-to-end, 833 
 lateral, 834 
 Murphy button, 839 
 localization, 825 
 stasis, 899 
 sutures, 828 
 
 tract, internal fistula^, 891 
 Intestine, gunshot wound, 845 
 
 hemorrhage of, in typhoid, 893 
 obstruction, 884 
 acute, 885 
 chronic, 889 
 diagnosis, 886 
 oi)eration, 888 
 treatment^, 887 
 perforation of, suture in, 829 
 
 in typhoid, 892 
 resection, 831 
 rupture, 843 
 surgery, 884 
 tumors, 894 
 wounds, 830 
 Intoxication, 70 
 Intracerebral hemorrhage, 570 
 Intracranial hemorrhage in newborn, 576 
 Intradural hemorrhage, 575 
 Intrathoracic operations, anesthetic, 153 
 Intratracheal insufl^ation, 154 
 Intravenous transfusion, 145 
 Intubation, 668 
 
 Intussusception, treatment, 889 
 Involucrum, 426 
 lodin disinfection, 141 
 Irreducible hernia, 759 
 Ischemic contracture, 540 
 Ischiatic hernia, 801 
 Ischio-rectal abscess, 607, 903 
 Italian rhinoplasty, 621 
 
 Jacksonian epilepsy, 590 
 Jackson's membrane, 896 
 Jacob's ulcer, 123 
 Jaw, carcinoma, 660 
 
 fractures, 321 
 
 osteomyelitis, 658 
 
 necrosis, 658 
 
 sarcoma, 661 
 
 surgery, 657 
 
 tumors, 660 
 Jejunum, peptic ulcer, 880 
 Joint, Charcot's, 460 
 
 mice, 461 
 Joints, ankylosis, 467 
 
 atrophic lesions, 452 
 
IXDEX 
 
 112' 
 
 oiiits, ('(mtusioiis, lis") 
 
 (iiscascs, Aiil 
 
 ilystropliifs, l-')' 
 
 i>iasii)ii, 4S() 
 
 ^imsliot wouiids, ISC) 
 
 hypcrtropliic lesions, !.)() 
 
 infect ion, -Uil, 47 1_ 
 {i;»)no<'o('('i(', 47 1 
 metastatic, 47!^ 
 pneuniococcic, 471 
 
 injuries, iiS") 
 
 loose l)0(lies in, 4(11 
 
 neuropatiiic, 400 
 
 .sarcoma, aO.S 
 
 syphilis, 'A)'-i 
 
 tuberculosis, 47(1 
 
 lumofs, M'A 
 
 wounds, 3S(1 
 
 Kadkk's jrastrostomy, S77 
 Kchr's incision, 928 
 operation, 933 
 Keloid, 109 
 
 Kelly's cystoscope, 960 
 Kidney, anomalies, 972 
 calculus, 977 
 carcinoma, 983 
 cyst, 984 
 dislocated, 973 
 floating, 973 
 functional capacity, 961 
 gunshot wound, 984 
 horseshoe, 972 
 hydrops, 976 
 infections, 973 
 injuries, 984 
 movable, 972 
 needling, 981 
 operations, 985 
 
 incisions, 985 
 sarcoma, 983 
 stab wound, 984 
 stone, 977 
 surgery, 958, 972 
 surgical, 975 
 tuberculosis, 982 
 tumors, 983 
 
 diagnosis, 953 
 Killian's operation, 657 
 Kink, Lane's, of ileum, 896 
 Knee, dislocation, 412 
 congenital, 515 
 excision, 469 
 tuberculosis, 498 
 knee-joint, amputation, 213 
 Knock-knee, 421 
 Knots, 166 
 
 Kobelt's tubules, 1099 
 Kraske's operation, 916 
 
 Lacerated wounds, 167 
 Laceration of cervix, 1081 
 
 Laceration of perineum, KtS'-' 
 Lacteal calculus, 701 
 Lacunar resorption, 41(1 
 liaminectomv, 601 
 Lane's kink,"s96 
 Laparotomy, MS 
 Larrey's amput;ition, 215 
 Laryngectomy, 672 
 Laryngo-fissure, 672 
 Laryngoscopy, 668 
 Larynx, carcunoma, 668 
 extirpation, 672 
 fracture, 667 
 intubation, 668 
 ])ai)illoma, 668 
 tumors, 668 
 Lateral anastomosis, 834 
 sinus, 567 
 j thrombosis, 577 
 
 ventricles, tapiiing, 555 
 j Laugier's hcu-nia, 794 
 ' Leeciiing, 147 
 Lee's amputation, 212 
 Leg, am|)utation, 212 
 fractures. 376 
 ulcer, 55 
 Leiomyoma, 114 
 Lembert suture, 828 
 Leontiasis ossea, 424 
 I Lepidomas, 106 
 j Leptomeninges, syphilis of, 579 
 I Leptomeningitis, 578 
 1 Leukocytosis, 31 
 I Lcuko-keratosis, 647 
 , Leukoma, 647 
 Leukopenia, 31 
 Leukoplakia, 647 
 Ligaments, shortening round, 1086 
 
 silk, 529 
 Ligation, 229 
 
 for aneurysm, 253 
 Lightning strokes, 222 
 Line of demarcation, 60 
 Linitis, plastic, 872 
 Lip, carbuncle, 641 
 cysts, 640 
 epithelioma, 641 
 surgery, 634 
 Lipoma, 107 
 
 arborescens, 503 
 of breast, 713 
 of neck, 684 
 Lipomatosis, 107 
 Liquor puris, 26 
 Lisfranc's amputation, 210 
 Lithectasy, 970 
 Litholapaxy, 970 
 Lithotomy, 970 
 
 perineal, 971 
 Lithotrity, 969 
 Litigation spine, 594 
 Littre's hernia, 755 
 Liver, abscess, 936_ 
 I anomalies, 935 
 
 I carcinoma, 941 
 
 cirrhosis, 940 
 
1128 
 
 INDEX 
 
 Liver, corset, 935 
 
 cyst, echinococcus, 93S 
 
 gunshot wounds, 847 
 
 linguiforin lobe, 935 
 
 Riedel's lobe, 935 
 
 rupture, 842 
 
 operation, 843 
 
 sarcoma, 942 
 
 surgery, 935 
 
 tumors, 941 
 Lockjaw, 90 
 Longitudinal sinus, rupture, 563 
 
 thrombosis, 577 
 Ludwig's angina, 645 
 Lumbar abscess, 607 
 
 hernia, 779 
 Lumpy jaw, 85 
 Lung, abscess, 748 
 
 decortication, 745 
 
 gangrene, 748 
 
 hernia, 736 
 
 injuries, 733 
 
 surgery, 669, 733 
 
 tuberculosis, 747 
 
 tumors, 749 
 Lupus vulgaris, 263 
 
 of cheeks, 624 
 Luxations, 387 
 Lymph, inflammatory, 24 
 Lymphadenitis, 269 
 
 of neck, 674 
 
 tuberculous, 676 
 Ly mphangeio-endothelioma, 1 28 
 L3'mphangeioma, 270 
 Lymphangeioplasty, 270 
 Lymphangeitis, 268 
 Lymphangiectasis, 269 
 Lymphatic varicocele, 269 
 Lymphatics, wounds, 268 
 Lymphedema, 270 
 Lymphization, 23 
 Lymphocytes, origin, 22 
 Lymphoma, 114 
 
 sarcomatodes, 272 
 Lymphomatosis, 114, 271 
 Lymphorrhea, 268 
 Lymphosarcoma, 116, 272 
 Lj^ssa, 96 
 
 M 
 
 McBitrney's incision, 820 
 
 point, 820 
 Macrocheilia, 640 
 Macroglossia, 644 
 Macromelia, 270 
 Madelung's deformity, 542 
 Madura foot, 86 
 Malar bone, fracture, 320 
 Malignant lymphoma, 271 
 
 pustule, 87 
 Mallein test, 90 
 Mammary abscess, 701 
 chronic, 701 
 
 gland. S(e Breast. 
 Mandible, dislocation, 391 
 
 Mandible, excision, 662 
 fracture, 321 
 tumors, 660 
 Mania a potu, 174 
 Manus valga, 542 
 Marginal ion, 20 
 Marjolin's ulcer, 123 
 Mastitis, acute, 700 
 
 carcinomatous, 719 
 chronic, 702 
 
 cystic, 706 
 stagnation, 700 
 .sj'philitic, 704 
 Mastodynia, 702 
 Mastoiditis, acute, 630 
 operation, 632 
 Matas's operation, 257 
 Mattress suture, 831 
 Maunsell's operation, 834 
 Maxilla, excision, 662 
 fracture, 321 
 tumors, 660 
 Mayo Robson's incision, 820, 928 
 Mayo's operation, 244 
 Meckel's diverticulum, 891 
 Mediastinitis, 732 
 
 Mediastinum, anterior, surgery of. 732 
 Medio-tarsal joint, amputation, 211 
 
 dislocation of, 415 
 Megacolon, congenital, 900 
 Melanoma, 129 
 Melon-seed bodies, 478 
 Meloplasty, 624 
 
 Meninges, surgical affections of, 567 
 Meningitis, 578 
 amicrobic, 579 
 epidemic cerebrospinal, 578 
 serous, 579 
 ^ spinal, 618 
 
 j tuberculous, 579 
 
 j meningocele, 553, 592 
 
 Meningomyelocele, 592 
 ! ISlercier catheter, 1034 
 Merocele, 793 
 Mesenteric cysts, 895 
 embolism, 890 
 thrombosis, 890 
 Mesosigmoiditis, 898 
 Mesothelioma, 127 
 Metacarpal amputation, 206 
 Metacarpus, dislocation, 404 
 
 fracture, 361 
 Metastatic abscess, 73 
 Metatarsalgia, anterior, 547 
 Metatarsus, dislocation, 415 
 
 fracture, 384 
 Metritis, 1074 
 acute, 1074 
 chronic, 1075 
 septic, 1094 
 Michel's clamps, 166 
 Microcephalus, 554 
 Microdactylia, 275 
 Micrognathy, 659 
 Middle meningeal hemorrhage, 575 
 Migration, 20 
 
IXDEX 
 
 1120 
 
 Mikulicz's (lis(>asc, ()2() 
 ■ Miner's elbow," 2()7 
 Minor sin^ery, 142 
 Mixed clwineie, 991 
 
 tumors, 1()() 
 Muleculiir ileath, .VJ 
 Molluscuin lihrosuni, "-'915 
 Moiiibur^'s lieinostasis, "JHi 
 Moiiorcliiilism, 1050 
 Morbus coxa; senilis, 45() 
 Mortification, 5S 
 MosetiK-Moorhof bone-wax, 485 
 "Mother's mark," 244 
 Mouth-wash, iodo-glvcerolc, (152 
 Movable kidney, 972' 
 
 spleen, 955 
 Mucous patches, 995 
 Mummery's operation, 910 
 Murphy button, S.39 
 Muscle, congenital alisence, 505 
 
 contracture, 27G 
 
 rupture, 274 
 
 tumors, 277 
 
 \v(junds, 273 
 Muscular hernia, 274 
 Myelogenous leukemia, 113 
 Myeloma, 113 
 
 giant-celled, 113 
 Myelomatosis, 113 
 Myocarditis, postoperative, 177 
 Myorua, 114 
 
 malignant, 110 
 
 of uterus, 1102 
 
 sarcomatofles, 116 
 Myomectomy, 1106 
 Myo-sarcoma, 116 
 Myositis, 274 
 
 ossificans progressiva, 275 
 traumatica, 274 
 
 traumatic, 274 
 Mj'ringotom}', 630 
 Myxedema, 688 
 Myxo-lipoma, 108 
 Myxoma, 109 
 Myxo-sarcoma, 109 
 
 N 
 
 Nasal bones, fracture, 320 
 Naso-pharjmx, tumors, 665 
 Neck, deformities, 537 
 
 fibroma, 684 
 
 ligneous phlegmon, 673 
 
 lipoma, 684 
 
 lymphadenitis, 674 
 
 operations, anesthetic, 153 
 
 surgery, 673 
 
 woody phlegmon, 673 
 
 wounds, 673 
 Necrosis, 58, 431 
 
 jaws, 658 
 
 liquefaction, 59 
 Needles, 164 
 
 operative, removal of, 169 
 Needling kidney, 981 
 Negri bodies, 97 
 
 iNelaton's line, 3()4 
 Neoplasm. Sec Tumors. 
 Nephrectomy, 987 
 Nephritis, .sejjtic, 974 
 
 toxic, 974 
 Ncplu'olithiasis, 977 
 
 simple, 978 
 
 treatment, 9S0 
 Nei)hrolithotomy, 980 
 Nephropexy, 973, 987 
 Nephroptosis, 972 
 Nephrr)tomy, 980, 986 
 Nerve aiiiistomosis, 286 
 for talipes, 527 
 
 blocking, 157 
 
 contusion, 2S2 
 
 dislocation, 283 
 
 gunshot wounds, 186 
 
 laceration, 283 
 
 regeneration, 287 
 
 rupture, 282 
 
 stretching, 283 
 
 tumors, 293 
 
 woimds, 284 
 Nervous system in inflammation, 27 
 Neuralgia, 288 
 
 of breast, 702 
 
 sciatic, 292 
 
 trifacial, 289 
 Neuralgic ulcer, 54 
 Neurectasis, 288, 292 
 Neurectomy, 288 
 Neurinomas, 293 
 Neuritis, 287 
 Neurofibromatosis, 293 
 , Neurolysis, 288 
 I Neuroma, 114 
 ] amputation, 114 
 
 false, 114 
 Neuropathic joints, 460 
 Neuroplasty, 286 
 Neurorrhaphy, 285 
 I Neurotomy, 288 
 j intra-perineural, 530 
 
 Nevoid lipoma, 246 
 Nevus pilosus, 245 
 
 vasculosus, 244 
 Newborn, intracranial hemorrhage, 576 
 Nipple, affections, 699 
 
 excoriation, 700 
 
 fissures, 700 
 Paget's disease, 719 
 j Nitrous oxide anesthesia, 152 
 I Noma, 63 
 ; pudendi, 63 
 
 j Nou-union in fractures, 316 - 
 I Nose, acne rosacea, 620 
 foreign bodies, 620 
 I saddle, 620 
 
 j surgery of, 619 
 
 Nose-bleed, 619 
 
 Obstruction, choledochus, 928 
 intestinal, 884 
 
1130 
 
 INDEX 
 
 Ohsti'iiction, intestinal, Jicute, SS") 
 treatment, 887 
 chronic, 889 
 
 pyloric, 868 
 Obturator hernia, 799 
 Ochsner treatment, 811 
 Odontomas, 112 
 Olecranon, fractin'e, 348 
 Omentum, cyst, 895 
 Omphalectomy, 777 
 Onychauxis, 260 
 Onychia, 260 
 Oophorectomy, 1080 
 Oophoritis, 1078 
 Operation, 818 
 
 ablation of breast, 721 
 
 adenectomy, 077 
 
 Agnew's, 506 
 
 air passages, 668 
 
 Alexander's, 1086 
 
 amputations, 192 
 bi'east, 710 
 
 anastomosis, intestinal, 832 
 
 Anel's, for aneurysm, 254 
 
 anesthesia, 148 
 
 anem-ysmoplasty, 258 
 
 ante-thoracic esophago-jejuno-gas- 
 trostomy, 696 
 
 Antyllus, 255 
 
 appendicectomy, 855 
 
 appendicostomy, 896 
 
 arthrectomy, 486 
 
 arthrodesis, 528 
 
 arthroplasty, 471 
 
 astragalectomy, 521 
 
 Ashhurst's amputation, 212 
 excision, 469 
 
 Bassini's, 787 
 
 Beck's, 1044 
 
 Berger's, 210 
 
 bile-duct, 928 
 
 Billroth's amputation, 216 
 gastrectomy, 881 
 
 Bottini's, 1036 
 
 "Bottle," 1060 
 
 Brasdor's, for aneurysm, 255 
 
 castration, 1056 
 
 cecostomy, 896 
 
 cholecystectomy, 931 
 
 cholecystendysis, 930 
 
 cholecystenterostomy, 934 
 
 cholecysto-duodenostomy, 934 
 
 cholecysto-gastrostomy, 934 
 
 cholecystostomy, 930 
 
 cholecystotomy, 930 
 
 choledocho-enterostomy, 928 
 
 choledochostomy, 932 
 
 choledochotomy, 932 
 
 chondrectomy, 748 
 
 Chopart's amputation, 211 
 
 cleft Dalate, 638 
 
 Cock's, 1025 
 
 colostomy, 915 
 
 colpo-perineorrhaphy, 1083 
 
 colporrhaphy, 1083 
 
 craniotomy, 586 
 
 Operation, Cushing's decompressive. 590 
 cystocele, 1088 
 cystotomy, 970 
 Demarquay's, 1018 
 Didot's, 506 
 Dudley's, 1070 
 
 Dupuytren's ami)utation, 209 
 endo-aneurysmorrhaphy, 257 
 epiploi)ex3', 941 
 erasion of joints, 486 
 esophagotomy, 694 
 Estlander's, 746 
 excision, ankle, 500 
 
 elbow, 470 
 
 hip, 497 
 
 knee, 469 
 
 mandible, 662 
 
 shoulder, 470 
 
 superior maxilla, 062 
 
 of tongue, 651 
 
 tumors in general, 131 
 
 urethral stricture, 1018 
 
 wrist, 470 
 extirpation, aneurysmal sac, 256 
 Finney's pyloroplasty, 879 
 Frazier-Spiller, 292 
 gastreetomj^ 881 
 gastro-anastomosis, 872 
 gastrogastrostomy, 872 
 gastrojejunostomy, 879 
 gastroplasty, 871 
 gastrostomy, 877 
 gastrotomy, 876 
 Gersuni's, 910 
 goitre, 687 
 
 Gritti's amputation, 213 
 Guthrie's amputation, 214 
 Hancock's amputation, 211 
 hemilarj'ngectomy, 672 
 hepatico-enterostomy, 928 
 hernia, 787 
 
 Hey's amputation, 210 
 Hunter's, for aneurysm, 254 
 hj'sterectomj', 1 106 
 hj'steropex}^ 1086 
 intestinal anastomosis, 832 
 Kader's gastrostomy, 877 
 kidney, 985 
 KiUian's, 657 
 Kraske's, 916 
 laminectomy, 001 
 laparotomj^, 818 
 LaiTey's amputation, hip, 215 
 
 shoulder, 209 
 LeConfe's amputation, 210 
 Lee's amputation, 212 
 Ligation for aneurj'sm, 254 
 
 of arteries, 230 
 Lisfranc's amputation, 210 
 lithectasy, 970 
 litholapaxy, 969 
 lithotomy, 970 
 lithotrity, 969 
 Littre's, 902 
 
 Matas's, for aneurysm, 257 
 JNlaunsell's, 834 
 
IXDKX 
 
 1131 
 
 Opcnitioii, Mayo's, 2-H 
 Muiiiinciy's, iUO 
 iu'plin'<'t(iiny, 'J.S7 
 neplirulithotoiny, !>S() 
 ni'ijliropcxy, OS? 
 nephrotomy, 980 
 neurectomy, 2.SS 
 neurorrhaphy, '2S't 
 neurotomy, 2S.S 
 omphalectomy, 777 
 oophorectomy, 1080 
 orcliidectomy, lOoO 
 orchidopexy, lO.il 
 osteophistic, 504 
 osteotomy, 420 
 ovariotomy, 629 
 pancreatectomy, 9.51 
 paracentesis for ascites, 940 
 Peck's, 916 
 pericardiotomy, 237 
 perineal section, 1024 
 peritonitis, 862 
 pharvngotomv, 664 
 Phelps's, 520 
 phlebectomy, 244 
 phlebotomy, 147 
 Pirogoff's amputation. 211 
 pleurotomy, 742 
 pneumonectomy, 747 
 pneumonotomv, 747 
 Pozzi's, 1070 
 proctotomy, 912 
 prostatectomy, 1036 
 prostatotomy, 1036 
 pyelotomy, 980 
 pylorectomy, 881 
 pyloroplastj', 878 
 rhinoplasty, 620 
 Ruggi's, 797 
 salpingectomy, 1080 
 salpingo-oophorectomv, 1079 
 Schede's, 243 
 Schomacker's, 910 
 Schroeder's, 1073 
 Sedillot's amputation, 212 
 Senn's amputation, 215 
 sequestrotomv, 433 
 Siter's, 1036 ' 
 Skey's amputation, 210 
 skin-grafting, 224 
 Spence's amputation, 209 
 splenectomy, 957 
 Stamm's gastrostomy', 877 
 staphylorrhaphy, 638 
 Stokes's amputation, 213 
 stomach, 876 
 SjTne's amputation, 211 
 urethrotomy, 1022 
 sjinpathectomy, 692 
 Teale's amputation, 207, 212 
 tenotomj- for talipes, 519 
 Terrier's, 932 
 Textor's amputation, 211 
 Thomas's plastic resection of breast, 
 
 711 
 thoracoplasty, 746 
 
 Operation, thoracotomy, 712 
 
 thyroidectomy, 692 
 
 thyrotoniN', 672 
 
 tongue. (■»,53 
 
 tracheloplasfy, lOSl 
 
 trachelorrhaphy, 1081 
 
 tracheotomy, 670 
 
 Trendelenburg's, 243 
 
 tre|)hining skull, 563 
 
 uraiKjplastj', 638 
 
 ureterolithotomy, 981 
 
 urethrotomy, 1022 
 
 vaginal hysterectomy, 1108 
 
 ventro-fixation of uterus, 1087 
 
 Wardrop's for aneury.sm, 255 
 
 Warren's, 711 
 
 Whitehead's, hemorrhoids, 908 
 tongue, 653 
 
 wiring aneurj-sm, 256 
 
 Witzel's gastrostomy, 877 
 
 Young's, 1041 
 Opsonic index. 45 
 
 theory, 44 
 Opsonins, 23 
 Orchidectomy, 1056 
 Orchidopexv, 1051 
 Orchitis, 10o2 
 Orthopedic surgerv, 504 
 0.steitis, 426 
 
 deformans, 423 
 
 fibrous, 437 
 Osteo-arthritis, 452 
 
 metabolic, 452 
 Osteoclasis, 420 
 Osteogenesis imperfecta, 416 
 Osteoma, 111 
 
 malignant, 447 
 
 sarcomatodes, 447 
 Osteomalacia, 423 
 Osteomyelitis, 426 
 
 albuminous, 429 
 
 chronic, 431 
 
 jaw, 658 
 
 ribs, 732 
 
 treatment, 428 
 
 vertebrae, 602 
 Osteophyte, 112 
 Osteoplastic craniotomy, 586 
 
 operations, 504 
 Osteoporosis, 416 
 Osteopsathyrosis, 416 
 Osteosarcoma, 116, 447 
 Osteotomy, 420 
 
 for ankylosis, 468 
 
 subtrochanteric, 487 
 Othematoma, 629 
 Otitis media, 629 
 Ovariotomj', 1101 
 Ovaritis, 1078 
 Ovary, abscess, 1078 
 
 cyst, 1097 
 
 dermoid, 1101 
 retention, 1097 
 
 cystadenoma, 1098 
 papuliferous, 1098 
 
 embryomas. 1101 
 
1132 
 
 INDEX 
 
 Ovary, teratoma, 1101 
 tumors, 1101 
 
 diagnosis, 953 
 
 Pachymeningitis, 578 
 Paget's disease of bone, 423 
 
 of nipple, 719 
 Painful heel, 549 
 Palate, perforations of, 640 
 Palmar abscess, 279 
 
 fascia, contracture of, 542 
 Palsy, brachial birth, 783 
 
 cerebi'al, 530 
 
 crutch, 282 
 
 infantile, 521 
 
 post-anesthetic, 282 
 Panaris, 279 
 Pancreas, abscess, 946 
 
 carcinoma, 950 
 
 operation, 951 
 
 cysts, 952 
 
 fistula, 946 
 
 gangrene, 946 
 
 gunshot wounds, 847 
 
 infections, 943 
 
 surgery, 943 
 Pancreatectonw, 951 
 Pancreatic calculi, 949 
 
 insufficiency, 947 
 
 lymphangeitis, 946 
 
 reaction, 948 
 Pancreatitis, acute, 944 
 
 chronic, 946 
 
 treatment, 949 
 
 hemorrhagic, 944 
 Pancreato-enterostomj^ 951 
 Pan-hysterectoim% 1106 
 Papilloma, 118 
 
 of bladder, 966 
 
 intracj'stic, 118 
 
 of larynx, 668 
 Papillomatous growths of scalp, 553 
 Paralytic talipes, 521 
 Paraphimosis, 1048 
 ParathjToids, 691 
 Paronvchia, 279 
 Parotid bubo, 624 
 
 tuberculosis, 625 
 
 tumors, 625 
 Parotitis, infectious, 624 
 
 symptomatic, 624 
 Parovarian cyst, 1099 
 Partridge's hernia, 794 
 Patella, dislocation, 279 
 
 fracture, 372 
 Peck's operation, 916 
 Pectineal hernia, 794 
 Pelvic abscess, 1077, 1096 
 
 bones, fractm-e, 323 
 
 cellulitis, 1094 
 Pelvi-rectal abscess, 904 
 Pelvis, bimanual examination, 1068 
 
 static disorders, 535 
 
 Penis, amputation, 1050 
 
 carcinoma, 1049 
 
 congenital deformities, 1043 
 
 extirpation, 1050 
 
 surgery, 1043 
 Peptic ulcer of jejunum, 880 
 Perforating ulcer, 261 
 Perforation of gall-bladder, 921 
 
 of intestine, 829 
 typhoid, 892 
 
 of uterus, 1093 
 Periarthritis, 466 
 Pericarditis, cardiolysis in, 237 
 Pericardiotomy, 237 
 Pericholecystitis, 920 
 Pericolitis, 896 
 
 sinistra, 897 
 Perimetritis. 1094 
 Perineal liernia, 800 
 
 prostatectomv, 1040 
 Perineoi)lasty, 1083 
 Perinephric abscess, 977 
 Pei'ineum, laceration, 1082 
 Perinorrhaphy, 1083 
 Pei'iosteal sarcoma, 447 
 Periosteitis, acute, 425 
 
 alveolar border, 660 
 
 chronic, 425 
 Perisigmoiditis, 897 
 Perithelioma, 128 
 Peritoneal adhesions, 814 
 Peritoneum, 802 
 
 tuberculosis, 815 
 Peritonitis, 802 
 
 acute diffuse, 806 
 local, 805 
 
 causes, 803 
 
 clinical course, 805 
 
 diffuse, 804 
 
 operation, 862 
 
 distention, 808 
 
 fibrino-purulent, 804 
 
 general, 806 
 
 hemorrhagic, 805 
 
 idiopathic, 803 
 
 Ochsner treatment, 811 
 
 operation, 862 
 
 pathology, 803 
 
 pneumococcic, 815 
 
 rigidity, 806 
 
 septic, 805 
 
 spreading, 804 
 
 starvation treatment, 811 
 
 sj^mptoms, 805 
 
 tenderness, 808 
 
 toxic, 805 
 
 treatment, 810 
 Peritonsillar abscess, 663 
 Peri-urethral abscess, 1027 
 Pernio, 222 
 Pes planus, 547 
 Petechia, 159 
 Phagedenic ulcer, 54 
 Phagocj-tes, 23 
 Phagocytosis, 23 
 Phalanges, dislocation, 404 
 
IM)KX 
 
 1133 
 
 Phalann(-s, fracliirc, 3()'_', 3S4 
 Plianiifiotoiny, lateral, ()(> I 
 
 siihliyoid, (Wi") 
 
 SMi)raliy()i(l, (i(t I 
 Pliolps's ()|)<Mati<)ii, .")L'(1 
 I'lifiiol-siilplioMcplitlialciii tcsl, '.Mil 
 IMiiiiiosis, 104') 
 
 froatiiu'iil, 10 U) 
 Phl('l)(>ctasis, •J12 
 riilchoctoiny, 244 
 I'hlchitis, 2;ls 
 
 post-optTalivc, 240 
 
 Iroat incut. 240 
 Phl.'holiths, 2;W 
 l'hlch()scl(>r()si.s, 28.S 
 Plil(4)otoiiiy, 147 
 PiilcKiiioii, 2(5, 47 
 
 Phosphorus jioisoninf;;, hones in, (558 
 Picric acid dressing;, 219 
 Pijinicntod mole, 24.") 
 Piles. !)()() 
 Pilo-nidal cyst, 2()() 
 
 fistula, 2()6 
 PiroRoff's amputation, 211 
 V. Pirquot's test, 81 
 Plaster jacket, 610 
 Piaster of Paris, 137 
 Plastic linitis, 872 
 
 surgery, 225 
 Pleura, disci.ssion, 74G 
 
 injuries, 733 
 
 surgery, 733 
 
 tuberculosis, 746 
 
 tumors, 749 
 Pleural fistula, 744 
 Pleurisy, 739 
 Pleuritis, 739 
 Pleurotomy, 742 
 Plexiform neuroma, 293 
 Plombage, 435 
 Pneumococcic joint infection, 471 
 
 peritonitis, 815 
 Pneumo-hemothorax, 738 
 Pneumonia, post-operative, 177 
 Pneumonectomy, 747 
 Pneumonotomy, 747 
 Pneumothorax, 737 
 Points douloureux, 289 
 Poisoned wounds, 170 
 Poliomj^elitis, anterior, 521 
 Polvdactylism, 505 
 Polymastia, 699 
 Polypus, naso-pharyngeal, 665 
 
 rectal, 913 
 
 uterus, 1103 
 Polythelia, 699 
 "Port-wine" stauj, 244 
 Post-anesthetic palsj', 282 
 Post-operative deaths, 176 
 
 embolism. 178 
 
 fat-embolism. 178 
 
 heat prostration, 179 
 
 mvocarditis. 177 
 
 phlebitis, 240 
 
 pneumonia, 177 
 
 sepsis, 177 
 
 I'ost-operativc status Ivniphaticus, 178 
 Pott's di.scase, 602 
 
 abscess, 606 
 
 treatment, 613 
 contractures, treatment, 614 
 ()l)erativ(! fixation of spine. 61'J 
 I)arai)legia, 608 
 treatment, 609 
 
 fracture, 380 
 Pozzi's operation, 1070 
 Pre-cancerows changes, 121 
 Pregnancy, extra-uterine. 1090 
 
 treatment, 1092 
 Prepuce, atlherent, 1046 
 
 redundanciy, 1046 
 Probe, eyed, 49 
 Procidentia recti, 909 
 
 uteri, 1088 
 Proctitis, 910 
 Proctoclysis, 144 
 Proctoscope, 901 
 Proctotomy, 912 
 Profeta's law, 999 
 Prolapse of rectum, 909 
 
 of urethra. 1018 
 
 of uterus, 1088 
 Properitoneal inguinal hernia, 784 
 Prostate, abscess, 1028 
 
 adenomatosis, 1030 
 
 atrophy, 1041 
 
 carcinoma, 1042 
 
 enlargement, 1029 
 operation, 1036 
 treatment, 1034 
 radical. 1036 
 
 hypertrophy, 1029 
 
 sarcoma, 1042 
 
 surgery, 1028 
 Prostatectomy, 1036 
 
 perineal, 1040 
 
 suprapubic, 1038 
 Prostatotomy, perineal, 1036 
 Prostatitis, acute, 1028 
 
 chronic, 1028 ' 
 "Proud flesh," 53 
 Psammoma, 128 
 Pseudoleukemia infantium, 957 
 Psoas abscess, 607 
 Ptomains, 19 
 Pudendal hernia, 800 
 Puerperal pyemia, 1093 
 
 sepsis, 1092 
 "Pulled elbow," 403 
 Pulmonary embolism. 178, 241 
 
 <)steo-arthro))athy, 475 
 Punctured wounds. 169 
 Pus, 25 
 
 absorption, 26 
 
 encapsulated. 26 
 
 gummatous, 84 
 Pus- tube, 1076 
 
 rupture, 1077 
 Py arthrosis. 462 
 Pyelitis. 974 
 Pyelo-nephritis. 974 
 Pyelotomy, 980 
 
1134 
 
 INDEX 
 
 Pyemia, 73 
 
 puerperal, 109G 
 
 symptoms, 74 
 
 treatment, 74 
 
 tuberculous, <S() 
 Pylorectomy, S81 
 Pyloroplasty, 878 
 
 riimey\s, 879 
 Pylorospasm, 869 
 Pylorus, obstruction, 868 
 
 stenosis, 869 
 Pyogenesis, 25 
 Pyogenic bacteria, 28 
 
 membrane, 26 
 Pyonephrosis, 977 
 Pyosalpinx, 1076 
 Pyothorax, 739 
 Pyrexia, 70 
 
 Quinsy, 663 
 
 Rabies, 96 
 
 Racemose aneurysm, 247 
 Rachitic rosary, 726 
 Rachischisis, 592 
 Rachitis, 417 
 
 osteoclasis, 420 
 
 osteotomy, 420 
 Radio-carpal joint dislocation, 403 
 Radius, fracture, 350 
 
 head of, dislocation, 402 
 Railway sjjine, 594 
 Rankenneurom, 293 
 Ranula, 645 
 Ray fungus, 84 
 Raynaud's disease, 64 
 V. Recklinghausen's disease, 293 
 Rectocele, 1082 
 Recto-genital fistula, 913 
 Recto-urethral fistula, 913 
 Recto-urinary fistula, 913 
 Recto-uterine fistula, 913, 1089 
 Recto-vaginal fistula, 913 
 Rectum, adenoma, 913 
 
 carcinoma, 913 
 
 false anus, 914 
 radical ojieratioii, 915 
 
 examination, 900 
 
 malformations, 901 
 
 polypus, 913 
 
 prola]jse, 909 
 
 stricture, 911 
 
 surgery, 900 
 
 tumors, 913 
 Redr(>ssement force, 519 
 Regeneration, 30 
 Renal calculus, 977 
 
 colic, 979 
 Repair, 29 
 
 in fractures, 303 
 
 in incised wounds, 161 
 Resection of breast, 711 
 
 I Resection of intestine, 831 
 Residual i)eritoneal abscess, 813 
 Restitutio ad integrum, 30 
 Retained secundines, 1093 
 Retention of urine, 1015 
 Retroflexion of the uterus, 1086 
 Retrognathism, ()59 
 Retrograde catheterization, 1025 
 Retroversion of the uterus, 1086 
 j Reverdin's skin-grafting, 224 
 'Rhabdomyoma, 106, 114 
 ! Rhagades, 1000 
 Rheumatic arthritis, 473 
 Rheumatism, tuberculous, 474 
 "Rheumatisme noueux," 452 
 Rheumatoid arthritis, 452 
 Rhinoplasty, 620 
 j Rhinoscleroma, 87 
 j Rhizotomy, 530 
 I Ribs, caries, 73 1 
 I cervical, 539 
 
 I fracture, 323 
 
 osteomyelitis, 732 
 Richter's hernia, 755 
 I Riedel's lobe, 935 
 i Ring fracture, 559 
 Rodent ulcer, 123 
 of cheeks, 624 
 Roller bandage, 133 
 Rose ulcer, 717 
 
 Round ligaments, shortening of, 1086 
 Rupture of abdominal wall, 840 
 bladder, 971 
 diaphragm, 750 
 gastro-intestinal tract, 842 
 heart, 236 
 liver, 842 
 muscle, 274 
 nerve, 282 
 pus-tube, 1077 
 spleen, 842 
 tendon, 27N 
 urethra, 1017 
 
 St. Anthony's fire, 67 
 "Habre-blade deformitv," 442 
 
 tibia, 1000 
 Saccular aneurysm, 249 
 Saci'o-iliac joint, dislocation, 405 
 
 tuberculosis, 502 
 Saddle nose, 620 ^ 
 
 Saline solution, 143 
 Salivary calculus, 627 
 
 fistula, 626 
 
 glands, surgery, 624 
 Salomon's test, 948 
 Salpingectomy, 1080 
 Salpingitis, 1075 
 Salpingo-oophorectom V, 1 079 
 Sajiremia, 71, 75, 1093 
 
 chronic, 75 
 Sarcocele, 1056 
 Sarcoma, 114 
 
ISDEX 
 
 11:^.5 
 
 Sarcnina, alveolar, 1 !•') 
 bono, AA{\ 
 (if brain, 'iSj 
 of breast, 713 
 classification. 11") 
 niant-celle"!. 1 13 
 of jaw, <'»<>1 
 of joint, 0(13 
 of kidney, !>S3 
 larse round-celleil, 1 1') 
 of liver, <)42 
 inodullarv, AM 
 mixed-celled, 115 
 osteoid, 447 
 jieriosteal, 447 
 of prostate, 1042 
 jniro, 110 
 of scalp, ")53 
 small round-eellcd, 115 
 spindle-celled, 115 
 of thyroid, 0!)2 
 of tonsil, ()<)4 
 tubular, 115 
 Sarco-sepsis, 71 
 Scalds, 217 
 
 Scalp, birth-injuries, 561 
 contusions, 551 
 cyst, dermoid, 553 
 epithelioma, 553 
 papillomatous growths, 553 
 sarcoma, 553 
 surgical affections, 551 
 tumors, 553 
 wounds, 552 
 Scajiula, congenital elevation, 514 
 dislocation, 394 
 fracture, 330 
 Scar tissue, 24 
 Schede's operation, 243 
 thoracoplasty, 746 
 Schmidt's test, 948 
 Schomacker's operation, 910 
 Schroeder's operation, 1073 
 Sciatica, 292 
 Scirrhus of breast, 715 
 Sclavo's serum, 89 
 Scoliosis, 531 
 
 treatment, 533 
 Scrofula, 76 
 Scrofuloderma, 264 
 Scrotmn. elephantiasis, 1062 
 epithelioma, 1063 
 papilloma, 1063 
 tumors, 1063 
 Scurvy, 423 
 Sebaceous cyst, 265 
 Semilunar cartilage, subluxation, 412 
 Sedillot's amputation,_212 
 Semino-vesiculitis, 1054 
 Senile arthritis, 456 
 Senn's amputation, 215 
 gastrostomy, 877 
 powder, 219 
 Sejjsis, 36, 70 
 
 post-operative, 177 
 puerperal, 1092 
 
 Sei)tic diarrhea, 806 
 nephrit is, 974 ^ 
 peritonitis, 805 
 Septicemia, 71 
 
 puerperal, 1094 
 Seciuestrotomy, 433 
 Setiuestrum, 426 
 ; Sera, 45 
 
 Sero-serous suture, 828 
 Serpiginous ulceration, 53 
 Serum, antistreptococcic, \.> 
 I therapy in inflammation, 4 1 
 
 I Shock, 172 
 
 electric, 222 
 erethistic, 173 
 insidious, 173 
 prevention, 174 
 psychical, 173 
 secondarj', 173 
 torpid stage, 173 
 treatment, 175 
 Shoulder dislocation, 394 
 congenital, 513 
 excision, 470 
 ; Shoulder-joint, amputation, 207 
 ; Sialo-Uthiasis, 627 
 I Sigmoid diverticulitis, 897 
 I hernia, 785 
 
 surgery, 895 
 tumors, 913 
 Sigmoiditis, 897 
 Sigmoidopexy, 910 
 Sigmoidoproctostomy, 912 
 Silicate of sodium dressing, 139 
 Silk ligaments, 529 
 Silverfork deformity, 351 
 Simple ulcer, 54 
 Simpson splint, 619 
 Sims's position, 1064 
 
 speculum, 1065 
 Sinus, 48, 52 
 
 thrombosis, 577 
 treatment, 52 
 tuberculous, 80 
 Sinusitis, 655 
 frontal, 656 
 maxillary, 656 
 Siter's operation, 1036 
 Skey's amputation, 210 
 Skiagraphy in fractures, 302 
 Skin, surgery, 259 
 Skin-grafting, 57, 223 
 
 Reverdin's method, 224 
 Thiersch's method, 223 
 Wolfe-Krause method, 225 
 Skull, caries, 439 
 
 congenital malformations, 
 
 553 
 dangerous area, 567 
 fi-actures, 557 
 base, 564 
 bm-sting, 558 
 by count erst roke, 558 
 ring, 559 
 treatment, 561 
 vault, 559 
 
1136 
 
 INDEX 
 
 Skull, injuries, 557 
 
 newborn, fracture, 564 
 
 osteomyelitis, 566 
 
 surgical affections, 553 
 
 temporar}' resection, 586 
 
 trephining, 563 
 
 wounds, 557 
 Sliding hernia, 785 
 Sloughing, 58 
 
 phagedena, 63 
 
 ulcer, 54 
 Small-shot wounds, 185 
 Smoker's patches, 647 
 Snake bites, 170 
 Snapping hij:), 546 
 Sounds, urethral, 1015 
 Spasmodic tic, 292 
 
 torticollis, 292 
 Speculum examination, 1065 
 Spermatocele, 1061 
 Spermato-cystitis, 1 054 
 Sphacelus, 58 
 Spina bifida, 592 
 
 anterior, 592 
 occulta, 592 
 
 ventosa, 113 
 Spinal anesthesia, 157 
 
 cord, concussion, 594 
 
 meningitis, 618 
 Spine, dislocation, 594 
 
 fractures, 594 
 
 gonococcic infections, 615 
 
 gunshot wounds, 189 
 
 injuries, 593 
 
 lateral curvature, 531 
 
 lumbar static disorders, 535 
 
 pneumococcic infection, 615 
 
 sprain-fracture, 594 
 
 stab wounds, 594 
 
 strains, 593 
 
 surgery, 592 
 
 tuberculosis, 602 
 
 tumors, 617 
 Spirochseta pallida, 82 
 Spleen, abscess, 955 
 
 cysts, 955 
 
 dislocated, 955 
 
 enlargements, 954 
 
 gunshot wounds, 847 
 
 movable, 955 
 
 rupture, 842 
 
 operation, 844 
 
 surgery, 953 
 
 tumors, 953 
 Splenectomy, 957 
 Splenic anemia, 955 
 Splenomegaly, 955 
 SpondA'litis, atrophic, 615 
 
 deformans, 615 
 
 hypertroi)hic, 616 
 
 traumatic, 602 
 
 typhoid, 615 
 Spondylolisthesis, 536 
 Spondvlose rhizomelique, 617 
 Sprain, 385 
 "Sprained ankle," 385 
 
 Sprain fracture, 298 
 
 of spine, 594 
 Sprengel's deformity, 514 
 
 incision, 928 
 Squirrhe en cuirassc, 717 
 Stab wounds, 170 
 
 of abdomen, 844 
 of diaphragm, 749 
 of spine, 594 
 of thorax, 733 
 Stagnant gall-bladder, 922 
 Stamm's gastrostomy, 877 
 Staphyk)rrhaphy, 638 
 Starch dressing, 139 
 Stasis cyanosis, 727 
 Status h'mphaticus, 178 
 Steatoma, 265 
 Steatorrhea, 947 
 Stenosis of cervix, 1070 
 Sterilization, 140 
 Sterno-clavicular dislocation, 392 
 Sternum, fracture, 322 
 
 tuberculosis, 732 
 Still's disease, 474 
 Stomach, carcinoma, 873 
 cirrhosis, 872 
 dilatation, acute, 869 
 
 secondary, 870 
 fibromatosis, 873 
 gunshot wounds, 846 
 hour-glass, 871 
 linitis, 872 
 operations, 876 
 .segmented, 871 
 surgerv, 864 
 ulcer, 864 
 
 acute, 865 
 chronic, 865 
 hemorrhage, 868 
 open, 865 
 operation, 867 
 perforation, 867 
 treatment, 866 
 Strains, back, 593 
 
 tendon, 279 
 Strangulated hernia, 761 
 Strangulation, 160 
 Strapping, 385 
 Strawberr}' gall-bladder, 922 
 Stricture of esophagus, 695 
 of rectum, 911 
 of urethra, 1018 
 Strumitis, 688 
 Stumps, (iisea,ses of, 200 
 end-bearing, 202 
 structure, 200 
 Stj'ptics, 229 
 Subastragalar amputation. 211 
 
 dislocation, 415 
 Subcranial abscess, 578 
 
 hemorrhage, 574 
 Subinvolution of uterus, 1086 
 Subluxation of jaw, 392 
 
 semilunar cartilage, 412 
 wrist, spontaneous, 542 
 Submammarv abscess, 702 
 
INDEX 
 
 1137 
 
 Subpectorul ahscpss, 730 
 Suhscripular abscess, 731 
 Siibtiocliiiiitcric osteotomy, AS7 
 Subuiimial (>xost<»sis, 444 
 SupernuiiHTary tinners, oO") 
 
 toes, 'lO'i 
 Sui>piiratioii, '2'i 
 
 without bacteria, 27 
 Suprapubic fistula, MYMi 
 
 pn)statectoiiiy, HY.iS. 
 Suprascapular abscess, 731 
 Supravesical hernia, 7!)J 
 Sur>iical fever, 71 
 
 infections, 70 
 
 kidney, 97') 
 
 technique, 133 
 Sutures, 162 
 
 absorbable. 162 
 
 Alb.nt-I.enibert. 829 
 
 Iniricd, ir)3 
 
 chain. 163 
 
 C'onnell's, .S34 
 
 Cushing's, 831 
 
 Czerny's, 829 
 
 deep. 163 
 
 Dupuvtren's, 831 
 
 Gelv's, 829 
 
 Halsted's, 831 
 
 hare-lip, 636 
 
 interrupted, 162 
 
 intestinal, 828 
 
 knots, 166 
 
 Lembert, 828 
 
 lock, 163 
 
 mattress, 831 
 
 Mayo's, 837 
 
 non-absorbable. 162 
 
 overhand, 163 
 
 quilled. 163 
 
 quilt, 163 
 
 sero-serous, 828 
 
 subcuticual . 16") 
 
 superficial, 163 
 
 through-and-through, 829 
 
 tongue and groove, 621 
 
 twisted, 636 
 SjTne's amputation, 211 
 
 operation, 1022 
 Symmetrical gangrene, 64 
 Sjinpathectomy, 692 
 Syncope, 173 
 Syndactylism, 506 
 Synovitis, 462 
 
 'chronic serous, 462 
 
 treatment, 463 
 Syphilis, 989 
 
 bone, 440 
 
 breast, 704 
 
 chancre, 83 
 
 complement-fixation test, 1001 
 
 condj'lomata lata, 995 
 
 contagion, 989 
 
 diagnosis, 1001 
 
 gummas, 84 
 
 hereditary, 998 
 
 insontium, 989 
 72 
 
 Sv 
 
 S\ 
 
 philis, joint, 503 
 
 Iej)tomeninges, 579 
 
 mucous patches, 995 
 
 pathology, 83 
 
 I)eriod of incubation, 83 
 
 pregnancy. 999 
 
 rashes, 995 
 
 salvarsan, 1005 
 
 .secondarv lesions, 83, 993 
 
 skin l«-si(".ns, 996 
 
 symptoms, first stage, 9!M) 
 second stage, !(!)3 
 third stage, 996 
 
 tertiarv, 996 
 
 testicle, 1056 
 
 tongue, 649 
 
 treatment, 1002 
 
 treponema pallidum. 1001 
 
 Wassermann test, 1001 
 philitic })ubo, 992 
 
 dactvlitis, 99S 
 
 panaris, 998 
 
 rupia, 996 
 
 tubercle, 996 
 I)hilodermas, 83, 994 
 philoma. brain, 581 
 ringomyelia, 461 
 ringomyelocele, 592 
 
 Talbot's iodo-gljcerole mouth wash, 
 
 652 
 Talipes, congenital, 515 
 
 nerve anastomosi.s, 527 
 
 paralytic, 521 
 
 tenotomj' in, 519 
 Tarsus, dislocation, 414 
 
 fracture. 382 
 
 tuberculosis, 500 
 Telangiectases, 244 
 
 Temporo-maxillarj- joint ankylosis, 659 
 Tendon-sheaths, tuberculosis, 279 
 Tendons, dislocation, 278 
 
 gunshot wounds, 186 
 
 rupture, 278 
 
 strains, 279 
 
 transplantation, 525 
 
 wounds, 277 
 Tenotomy for talipes, 519 
 Tenosynovitis, 279 
 Terato-blastoma, 105 
 Teratomas, 104 
 
 monsters, 105 
 
 fetal inclusion, 105 
 
 ovary. 1101 
 
 sacral, 106 
 Terrier's operation, 932 
 Tessier's hernia, 794 
 Testicle, congenital anomalies, 1050 
 
 gumma, 1057 
 
 inflammation, 1052 
 
 misplaced, 1050 
 
 neoplasms, 1057 
 
 neuralgia, 1054 
 
1138 
 
 IXDEX 
 
 Testicle, non-descent, 1050 
 
 sarcoma, 1058 
 
 surgery, 1050 
 
 syphilis, 1056 
 
 torsion, 1052 
 
 tuberculosis, 1054 
 
 tumors, 1057 
 
 wandering, 1050 
 Tetanus, 90 
 
 antitoxin, 94 
 
 carbolic acid injections, 96 
 
 chronic, 93 
 
 cryptogenetic, 91 
 
 nascentium, 91 
 
 pathology, 91 
 
 symptoms, 92 
 
 treatment, 94 
 Textor's amputation, 211 
 Theeitis, 279 
 
 Thiersch's skin-grafting, 224 
 Thigh, amputation of, 213 
 Thoracoplasty, 746 
 Thoracotomy, 742 
 Thorax, gunshot wounds, 189 
 
 operations, 736 
 
 stab-wounds, 733 
 
 wounds, 733 
 Thrombosis, 237 
 
 arterial, 241 
 
 cavernous sinus, 577 
 
 lateral sinus, 577 
 
 longitudinal sinus, 577 
 
 mesenteric, 890 
 
 sinus, 577 
 
 venous, 238 
 Thrombus, 160 
 Thj-mus gland, surgery, 693 
 Thyro-glossal cvsts, 681 
 
 fistula, 68 f 
 Th\Toid, carcinoma, 692 
 
 enlargement, 684 
 
 inflammation, 684 
 
 sarcoma, 692 
 
 surgery, 684 
 
 tumors, 692 
 Thvroidectomv, 692 
 Thyroiditis, 684 
 Thyrotomy, 672 
 Thyrotoxicosis, 688 
 Tibia, fracture of, 376 
 Tibio-tarsal joint dislocation, 413 
 Tic convulsif, 292 
 
 douloureux, 289 
 Toe, supernumerary, 504 
 Tongue, abscess, 647 
 
 carcinoma, 649 
 
 chancre, 649 
 
 excision, 651 
 
 gumma, 649 
 
 ichthyosis, 647 
 
 sarcoma, 649 
 
 surgery, 644 
 
 syphihs, 649 
 
 tuberculosis, 648 
 Tongue-tie, 644 
 Tonsil, surgery, 663 
 
 Tooth wounds, 170 
 Torsion, 229 
 Torticollis, 537 
 
 spasmodic, 292, 538 
 Tourniquet, 194 
 Toxemia, 70 
 
 cryptogenetic, 71 
 Toxic ne))hritis, 974 
 
 peritonitis, 805 
 Toxins, bacterial, 19 
 Trachelorrhaphy, 1081 
 Tracheloplasty,'l081 
 Tracheotomy, 670 
 Transcondylar amputation, 213 
 Transfusion, direct, 145 
 Transplantation, bone, 504 
 
 tendon, 525 
 Transverse myelitis, 608 
 Traube-Hering waves, 572 
 Traumatic asphj'xia, 727 
 
 delirium, 71, 173 
 
 fever, 71 
 Trendelenburg's operation, 243 
 Trephine, CJalt's, 563 
 
 Hudson's, 563 
 Trephining, skull, 563 
 Treponema pallidum, 82 
 Trichiniasis, 276 
 Trigger finger, 543 
 Trochanter, fracture, 368 
 Truss, 758 
 
 for inguinal hernia, 786 
 Tubal abortion, 1090 
 Tubular aneurysm, 249 
 Tubo-ovarian abscess, 1077 
 
 cyst, 1098 
 Tubercle, 77 
 Tuberculin, 78 
 
 test, 81 
 
 focal reaction, 81 
 Tuberculoma, brain, 581 
 Tuberculosis, 76 
 
 ankle, 500 
 
 appendix, 864 
 
 bladder, 965 
 
 bone, 437 
 
 breast, 704 
 
 carpus, 502 
 
 cutis, 263 
 
 diagnosis, 80 
 
 elbow, 501 
 
 hip, 488 _ 
 
 joints, 476 
 
 kidnev, 982 
 
 knee, 498_ 
 
 lungs, 747 
 
 lymph nodes, 269, 676 
 
 parotid, 625 
 
 pathology, 77 
 
 peritoneum, 815 
 
 V. Pirquet's test, 81 
 
 pleura, 746 
 
 ribs, 731 
 
 sacro-iliac joint,- 502 
 
 skin, 263 
 
 spine, 602 
 
i.\i)i':.\ 
 
 li:!'.) 
 
 Tlllicrcillosis, si)iii(', ahsccss, (lIMi 
 
 sfcTiiiim, TiVi 
 
 tarsus, ■)()(> 
 
 tendon slicallis, 27!) 
 
 tfsticK", 10.') t 
 
 tonfiiu', Ml 
 
 tiratmcnt, 82 
 
 wrist, r)()2 
 Tulxnculous cavity, SO 
 
 dactylitis, t.'ii) 
 
 {iraniilation tissue. 7!) 
 
 fiununa, 7!) 
 
 lynipiiadonilis of neck, (J7() 
 
 meningitis, 'u\) 
 
 peritonitis, SI") 
 
 l)yeinia, SO 
 
 rheumatism, 474 
 
 sinus, SO 
 
 ulcer, SO 
 Tufnell's treatment for aneurysm, 253 
 Tumors, 101 
 
 abdominal, diagnosis of, \)')'A 
 
 adenoma, 1 1!) 
 
 of alveolar bonier, 660 
 
 of appendix, 864 
 
 of bile-ducts, 942 
 
 of bladder, 966 
 
 blastoma, 104 
 
 blastomatoid, 107 
 
 of bone, 443 
 
 of brain, 581 
 
 of breast, 705 
 
 cachexia, 103 
 
 capsule. 102 
 
 carcinoma, 119 
 
 cartilaginous, 110 
 
 of carotid gland, 680 
 
 characteristics, 101 
 
 chloroma, 114 
 
 cholesteatoma, 129 
 
 chondroma, 100 
 
 chordoma, 114 
 
 classification, 104 
 
 consistency, 102 
 
 cylindroma, 128 
 
 cj'st formation, 103 
 sequestration, 130 
 
 cyst adenoma, 119 
 
 cystoma, 129 
 
 definition, 101 
 
 desmoid, 277 
 
 embryoma, 106 
 
 endosteoma, 111 
 
 endothelioma, 127 
 
 epithelioma, 121 
 
 excision, 131 
 
 fibroid, 114 
 
 fibroma, 108 
 
 fibro-myxoma, 109 
 
 fibro-sarcoma, 109 
 
 form, 101 
 
 formation, Cohnheim's theor}', 
 103 
 parasitic theory, 104 
 Ribbert's theory, 104 
 
 of gall-bladder, 942" 
 
 Tuniiirs, glidtn.i, I I 1 
 
 growth, 102 
 
 hylic, 106 
 
 malignant, I I I 
 
 hyi)ernci)hrom.'i, 127 
 
 oi' intestine, 894 
 
 intraspinal, 617 
 
 of jaw, 660 
 
 of joints, 5();i 
 
 keloid, 109 
 
 of kidney, 983 
 
 of larynx, 668 
 
 IcpidiV, 106 
 
 benign, 1 IS 
 malignant, 1 19 
 transitional, 127 
 
 lipoma, 107 
 
 of liver, 941 
 
 of lung, 749 
 
 lymphoma, I I 1 
 
 lymphomatosis, 1 14 
 
 malignancy, 103 
 
 mediastinal, 732 
 
 melanoma, 129 
 
 mesothelioma, 127 
 
 metastasis, 103 
 
 mixed, 1C6 
 
 of muscle, 277 
 
 myeloma, 113 
 
 myelomatosis, 113 
 
 myoma, 114 
 
 mj'xoma, 109 
 
 myxo-sarcoma, 109 
 
 of naso-pharynx, 665 . 
 
 of nerve, 293 
 
 neuroma, 114 
 
 odontoma, 112 
 
 osteoma. 111 
 
 ostoses, 112 
 
 of ovary, 1101 
 
 of pancreas, 950 
 
 l)apinoma, 118 
 
 of i)arotid, 624 
 
 l)erithelioma, 128 
 
 of pleura, 749 
 
 psammoma, 128 
 
 of rectum, 913 
 
 recurrence, 103 
 
 rhabdomyoma, 114 
 
 sarcoma, 114 
 
 of scalp, 552 
 
 of scrotum, 1063 
 
 of sigmoid, 913 
 
 of spleen, 953 
 
 of stomach, 873 
 
 terato-blastoma, 105 
 
 teratoma, 104 
 
 of testicle, 1057 
 
 theories of formation, 103 
 
 of thyroid, 692 
 
 xanthoma, 108 
 Tyloma, 259 
 Typhoid arthritis, 472 
 
 carriers, 927 
 
 hemorrhage, 893 
 
 perforation, 892 
 
1140 
 
 INDEX 
 
 Typhoid periosteitis, 42o 
 spine, 615 
 spondylitis, 615 
 
 Ulcer, 53 
 
 callous, 55 
 (luoflenal, 864 
 chronic, 865 
 hemoiThage. 868 
 pei-foration. 867 
 treatment, 866 
 edematous, 54 
 gastric, 864 
 acute, 865 
 callous, 865 
 chronic, 865 
 hemorrhage, 868 
 open, 865 
 operation, 867 
 perforation, 867 
 treatment, 866 
 healthy. 54 
 indolent, 55 
 inflamed, 54 
 irritable, 54 
 Jacob's, 123 
 leg, 55 
 
 strapping, 56 
 sj'philitic, 57 
 MarjoUn's, 123 
 neuralgic, 54 
 perforating, 60. 261 
 phagedenic, 54 
 repair. 53 
 rodent, 123 
 simple, 54 
 sloughing, 54 
 tuberculous, 80 
 varicose, 58 
 warty, 58 
 weak, 54 
 Ulceration, 26, 53 
 
 serpiginous, 53 
 Ulcus molle, 1005 
 Ulna, fracture, 348 
 Umbihcal fistula, 891 
 hernia, 774 
 
 .strangulated, 778 
 Union in fractures, 303 
 
 in incised wounds, 161 
 Urachal cvsts, 963 
 
 fistul?e, 963 
 Uranoplasty, 638 
 Ureter, catlieterization, 961 
 Ureteral calculus, 981 
 Uretero-cervical fistula, 1089 
 Ureterolithotomy, 981 
 Urethra, foreign bodies, 1016 
 prolapse, 1018 
 rupture. 1017 
 stricture, 1018 
 
 congenital. 1019 
 dilatation, 1021 
 
 Urethra, stricture, incision, 1022 
 
 inflammatory, 1018 
 
 inorganic, IfJlS 
 
 organic, 1019 
 
 perineal section, 1024 
 
 spasmodic, 1019 . 
 
 s\Tnptoms, 1019 
 
 traumatic, 1019 
 
 treatment, 1021 
 surgery, 1015 
 Urethral fever, 1026 
 Urethritis, female, 1071 
 gonococcic, 1010 
 non-gonococcic, 1014 
 Urethrotomy, 1022 
 Urinarv extravasation. 1017 
 fever. 1026 
 fistula, 1027 
 Urine, overflow with retention, 1016 
 residual, 1016 
 retention, 1015 
 Uterus, adenomyoma, 1105 
 anteflexion, 1086 
 anteversion, 1086 
 carcinoma, 1109 
 chorio-epithelioma, 1111 
 deciduoma malignum, 1111 
 didelphys, 1070 
 displacements, 1086 
 do\\iiward displacement, 1087 
 fibroid, 1102 
 fibrom\'oma, 1102 
 hysteropexy, 1086 
 malformation, 1070 
 myoma, 1102 
 perforation, 1093 
 polyp, 1103 
 procidentia, 1088 
 prolapse, 1088 
 retroflexion, 1086 
 retroversion, 1086 
 subinvolution, 1086 
 vcntrosuspension, 1087 
 
 Vaccixatiox, 143 
 Vaccines, 45 
 
 in inflammation, 44 
 Vagina, absence, 1069 
 Vaginal hysterectomy. 1108 
 
 operations, preparation, 1068 
 Vaginitis. 1071 
 
 chronic, 1072 
 \'alsalva's treatment for aneurysm, 256 
 Varicocele, 1061 
 
 operation, 1062 
 Varicose aneurysm, 235 
 
 veins, 242 
 
 ulcer, 58 
 Varix, 242 
 Vein, anesthesia, 158 
 
 entrance of air, 234 
 \'enereal di-seases, 989 
 
 warts, 259, 1049 
 
INDEX 
 
 1141 
 
 \'ciinus ;Ul('Ul>sm, I'.VA 
 
 iicvi, 21") 
 \'t'iitriil licriiia, 772 
 Vontriclos, tappiiifi; hit oral, 5r)0 
 Vontro-fixation oi" uterus, 1087 
 VontrosusixMisioM uterus, 1()S7 
 Verruca, 2")!! 
 
 Verruca' acuminata", lOlU 
 Vertebra, dislocation, .')!)4 
 Vertebra-, fracture, .'iit I 
 
 osteomyelitis, (i()2 
 \'erteljral colunui, dystropliies, (il") 
 \'esical calculus, !)()(> 
 Vesication, 142 
 
 Ve.sico-ut(>rine fistula, 913, 1089 
 Vesico-va^R-inal fistula, 913, 1089 
 Vicious circle, 880 
 Villous arthritis, 4(12 
 Visceroptosis, 898 
 Volkmann's contracture, 540 
 Volvulus, treatment, 889 
 A'ulva, carcinoma, 1112 
 
 imjierf orate, 10G9 
 Vulvitis, 1071 
 Wilvo-vafiinal abscess, 1071 
 
 W 
 
 Wakdiiop's ligation, 2.j.5 
 Wart, 259 
 
 venereal, 1049 
 Wart}' ulcer, 58 
 Wassermann reaction, 1001 
 Wax, Horsley's, 588 
 
 Mosetig-Moorhof's, 435 
 ''Weaver's bottom," 267 
 Webbed fingers, 506 
 \\m, 265 
 Whitehead's excision of tongue, 653 
 
 hemorrhoid operation, 908 
 
 varnish, 638 
 Whitlow, 279 
 Wille's test, 948 
 Wiring aneurysm, 256 
 Witzel's gastrostomy, 877 
 Wolfe-Krause skin-grafting, 225 
 Wool-sorter's disease, 87 
 Wounds, arrow, 170 
 
 arterio-venous, 235 
 
 bayonet, 170 
 
 bites, 170 
 
 blank cartridge, 186 
 
 bloodvessels, 233 
 
 bullet, 183 
 
 of burste, 266 
 
 contused, 167 
 
 drainage, 165 
 
 dressing, 166 
 
 gunshot, 180 
 
 of abdomen, 191, 844 
 of bloodvessels, 186 
 of bones, 186 
 character, 182 
 of diaphragm, 750 
 
 WOiiiids, gunshot, of liead, 188 
 of intestine, 845 
 (tf joints, 186 
 <(f liver, .S47 
 of lung, ISO 
 of nerves, 186 
 of pancreas, 847 
 of si)ine, 189 
 of sj)leen, 847 
 of stomach, 84() 
 of tendons, 18() 
 of thorax, 189 
 
 of heart, 236 
 
 incised, 160 
 
 dressing, 166 
 healing, 161 
 
 intestinal suture, 830 
 
 of joints, 386 
 
 lacerated, 167 
 
 of nuiscles, 273 
 
 of neck, 673 
 
 of nerves, 284 
 
 open, 16() 
 
 ])oisoned, 170 
 
 l)unctured, 169 
 
 of scalp, 552 
 
 of skull, 557 
 
 small shot, 185 
 
 snake l)ites, 170 
 
 stab, 170 
 
 of abdomen, 844 
 of diajihragm, 749 
 of thorax, 733 
 
 subcutaneous, 160 
 
 suture, 165 
 
 of tendons, 277 
 
 tooth, 170 
 Wrist, dislocation, 403 
 
 excision, 470 
 
 subluxation, 542 
 
 tuberculosis, 502 
 Wrist-joint amputations, 206 
 Wry-neck, 537 
 Wveth's method, 214 
 
 Xanthoma, 108 
 Xiphodynia, 322 
 X-ray dermatitis, 222 
 in fractures, 3C2 
 therapeutic uses, 223 
 
 YoiiN(i's operation, 1041 
 
 ZUCKER(;USSMA(JEN, 872 
 
 Zygoma, fracture, 320