COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00035068 ./ Cotumbm WLnibtx&ity tntteCttpofi^eto|9orfe Reboot of Cental anb &va\ burger? Reference Etfararp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/fracturesbycarlbOObeck Fracture of the tibia. Case illustrated by figure 139. Callus-formation two weeks after the injury. The anode was placed directly above the fractured area. The left leg was resting on the floor. The right leg was placed laterally, but, being supported, it was brought on a level with the anode. Thus it appears much the larger in proportion. FRACTURES BY CARL BECK, M.D. VISITING SURGEON TO ST. MARK'S HOSPITAL AND TO THE NEW YORK GERMAN POLIKLINIK; FORMERLY PROFESSOR OF SURGERY, NEW YORK SCHOOL OF CLINICAL MEDICINE: CONSULTING SURGEON, SHELTERING GUARDIAN SOCIETY ORPHAN ASYLUM, ETC. WITH AN APPENDIX ON THE PRACTICAL USE OF THE RONTGEN RAYS 178 ILLUSTRATIONS ff CJ&o-<^, ux UZ) 'Quidquid latet, adparebit, Nil occultum remanebit." PHILADELPHIA W. B. SAUNDERS & COMPANY i goo CM0\ Copyright, 1900, by W. B. Saunders & Company. TO Wtlbelm Conrafc iRontgen, WITHOUT WHOSE DISCOVERY MUCH OF THIS BOOK COULD NOT HAVE BEEN WRITTEN. PREFACE. During the past few years literature on the Rontgen ray has grown to large proportions. It has led to many and revolutionizing discoveries ; most of these have marked a clearer understanding, and consequently the better treatment, of fractures. Still, publications on this subject hitherto have not claimed to be more than tentative sketches or preliminary communications. This book is an effort to encompass in a systematic treatise the important essentials of the publications on this subject and such individual studies and experience as it has fallen to my lot to make. In these studies the Rontgen ray has verified the anatomic findings. It did so by exposing the fractures in their living state. The illustrations in older works were mainly made from the cadaver. The splendid schematic representations that resulted were not portraits from life. The minute arrangement and disarrangement of fragments and splinters, especially in their relations to the joints, were necessarily disarranged by even the most careful dissections. The Rontgen ray depicts these details and all others undisturbed and as they are in life. // is with tJicsc that the surgeon has to deal. Before Rontgen's epoch-making discovery it was just and proper to associate all studies of fractures with those of dislo- cations. The essential aim of this association necessarily was for purposes of differential diagnosis. Now, however, the student, made familiar with the various types of fracture, has no difficulty in recognizing and appreciating the various forms of dislocation. Moreover, the greater importance of the former is evident in the fact that fractures occur no less than 5 6 PREFACE. ten times as frequently (a longer experience with the Rontgen ray will probably make it fifteen times) as do dislocations. Furthermore, the after-treatment of fractures must be pre- dicated upon a thorough recognition of the anatomic rela- tions of the line of solution of osseous continuity, while in dislocations the therapy after reduction is very simple. Neces- sarily, the differentiation of the more frequent luxations, that closely resemble fractures, has received considerable attention in these pages. All the common, and some of the rarer, types of fracture are represented skiagraphically. The skiagrams and most of the drawings here presented are originals. They depict cases observed and treated in my dispensary, hospital, and private practice. Some illustrations are copied from Hoffa, von Berg- mann, Oilier, Nelaton, and Lejars. The skiagrams are exact reproductions of photographic prints. I resisted the temptation to emphasize their essential points by artistic interference, so that they represent the skia- graphic findings precisely as they are, with the exception of figures 107, 122, 151, and 169, in which the important points were lost during the process of reproduction. Figure 75 is treated schematically. It affords me special pleasure to here thank Professor Ront- gen for the many kindnesses of which I have been the re- cipient at his laboratory. My sincere acknowledgments are also due to Professors von Bergmann and Koerte, to Surgeon- General Stechow, of Berlin, and to Professors Hoffa and Gocht, of Wiirzburg, for many courtesies. The skiagraphic plates were developed by Mr. Joseph Byron, whom I desire to thank for his painstaking work. It also affords me pleasure to acknowledge my obligations to the publishers, W. B. Saunders & Company, for the typo- graphic and pictorial excellence of this book. Carl Beck. J7 East j 1 st Street, A T ew York. CONTENTS PAGE Introduction 9 PART I. FRACTURES IN GENERAL. Classification of Fractures 17 Statistics 20 Signs 21 Diagnosis 23 The Process of Repair and the Formation of Callus 26 Disturbances in the Process of Repair , 31 Treatment 34 Peculiarities of Fractures in Children 73 PART II. FRACTURES OF SPECIAL REGIONS. Fractures of the Shoulder and the Upper Extremity 78 Clavicle 78 Scapula 89 Humerus 92 Forearm 121 Hand and Fingers 161 Fractures of the Pelvis and the Lower Extremity 166 Pelvis 166 Thigh 168 Patella 193 Leg 204 Foot 226 Fractures of the Bones of the Trunk 232 Ribs 1 232 Sternum 238 Spinal Column 238 Fractures of the Skull 247 Vertex 248 P>ase 265 Facial Bones 26S APPENDIX. The Practical Use of the Rontgen Rays 277 Errors of Skiagraphy 311 Index 329 INTRODUCTION. Few scientific discoveries of the century have aston- ished the world more than that reported by Wilhelm Conrad Rontgen, of Wiirzburg-on-the-Main. The sig- nificance of this great discovery can not even yet be estimated. The preparatory researches that led to this dis- covery date from the time when Maxwell, extending and applying Faraday's theories, found that the phe- nomena of electricity depend upon the same principles as those of light. Both consist in vibrations of the ether that pervades the universe. Wiedemann, Yer- det, Kundt, Gassiot, Spottiswoode, and Rontgen tried to prove that the phenomena of electricity are in close connection with those of light, and not only that elec- tricity could produce light, but also that light could produce electricity. The correctness of these theories, however, could not be proved until the experiments of Wilhelm Hertz, a professor at the University of Bonn, brought conviction to the minds of even the most skeptical. Hertz showed that electric induction obeys the same laws as those governing the diffusion of light-waves. He also determined the speed of transmission of the electric wave, which he found to be equal to that of the light-wave. The phenomena of electric discharge in closed tubes, showing various degrees of exhaustion and filled with IO INTRODUCTION. different gases, had been the subject of experiment for many years, and a marked difference was noticed between the phenomena of light at the two electric poles. Light radiating from the positive pole extends entirely through a vacuum tube ; while light radiating from the negative pole produces only a very weak and diffused illumination. But as soon as the vacuum is increased to a high degree, the phenomena become entirely different. The light of the positive pole de- creases, while that of the negative pole pervades the vacuum more and more, being permanently propa- gated in straight lines. The light emanating from the negative pole is called the " cathode-ray y Lenard and Hittorf found that such rays have the power of creating fluorescence, heat, etc., and that they can be deflected by a magnet. The vacuum-tube that is commonly used is generally called the Crookes tube, after Sir William Crookes, who described and slightly modified the tube. The credit for having originally devised it is due to Geiss- ler, an ingenious mechanician of Bonn, Germany. As soon as an electric current of high intensity goes through the conducting wires fused into the ends of the tube, the negative electrode, or cathode, becomes surrounded by a faint dark-blue light, while the posi- tive electrode, the anode, sends a peach-colored light through the tube as far as the light of the cathode. As the air is gradually rarefied, the positive stream of light almost disappears, while the negative cathode light extends more and more, and finally fills the whole tube. In December, 1895, Rontgen, while experimenting with these tubes by surrounding them with black paste- board, impermeable by light, discovered an astonish- INTRODUCTION. I I ing phenomenon. On a screen standing near the tube, and painted with a light color (barium platinocyanid), he noticed a light as soon as an electric current went through the tube. It became evident at once that there was a radiant power that, although not percepti- ble to the eye, permeated the pasteboard. This force, heretofore unknown, also showed a marked effect on the screen. Rontgen, after having found that the effect of these invisible rays upon the screen was con- stant, tried photographic experiments also. He then discovered that under the influence of these rays his hand, resting upon the cover of a wooden box, gave a sharp silhouette on a drying plate below, although the cover was not removed. He also found that paper, wood, and even thin discs of metal, were permeable by the rays, while thick discs of metal, bones, etc., produced silhouettes. This latter discovery, in particu- lar, at once aroused the most wide-spread interest in regard to its uses in surgery, and up to the present date its full significance can hardly be appreciated. Rontgen modestly suggested naming the new rays "X-rays," until their nature should be discovered; but Professor Kolliker, of Wiirzburg, very properly pro- posed calling them "Rontgen rays," and the veteran scientist's recommendation will probably be followed by men of science and by the profession. The proofs of the great usefulness of the rays in sur- gery are now so overwhelming that to discuss them would be carrying owls to Athens. Their value in in- ternal medicine has not as yet been made so apparent ; still, much has been contributed in this field, and there can be no doubt that, with the better interpretation of the shadows and the continuous improvement of diag- nostic technic, the significance of the rays in many of I 2 INTRODUCTION. the obscurer ailments will be convincing to the mind of the most skeptical. The greatest usefulness of the rays thus far displayed is, however, in the recognition of fractures. Accuracy takes the place of ignorance and doubt, and painful manipulations cease to be necessary for diagnostic pur- poses. Even the most skilful experts in fractures are unable to deny that there is a large number of bone-injuries the character of which formerly could not be recognized, whether on account of the swelling of the area involved or from the obscurity of the symp- toms. The number of cases of fracture formerly mis- taken for contusion or distortion was enormous. It is in such cases that a simple glance with the fluoroscope furnishes the most precise evidence. Whether there is comminution or impaction or the intervention of muscular tissue or intra-articular fracture or combi- nation with a dislocation, can be at once clearly de- termined. If the picture be fixed on a photographic plate, the nature of the injury can be studied at leisure, and the proper line of treatment easily decided upon without subjecting the patient to any tentative manipu- lations. After a dressing is applied, the skiagram verifies the proper position of the fragments. In fact, the proper execution of all therapeutic points can be verified throughout the course of treatment by the skia- gram, the dressing itself, even if consisting of plaster- of-Paris, being no obstacle to the rays. Even the shoemaker can profit by the rays, which will prove whether shoes fit accurately — an item of great importance in the after-treatment of fractures or in club-foot. If the therapy proves to be imperfect, the rays show the nature of the condition. It is easily determined, INTRODUCTION. I 3 for instance, whether an ankylosis be fibrous or os- seous; and, consequently, the question whether the breaking-up of adhesions or resection is indicated is settled at once. It is needless to call attention to the frequent im- portance of a skiagraphic proof in court, for the pro- tection of the surgeon as well as of the patient. The greatest benefit obtained from the rays, in the proper judgment of the various types of fractures, is in connection with those situated in the neighborhood of joints. The special uses of the rays in diagnosticat- ing the various types of fracture may be grouped as follows : Fractures of the clavicle are, in general, easily rec- ognized without the rays. Still, there are rare cases of infraction and fissure in which no deformity or crepi- tus is observable, and which could not be recognized except by the aid of the rays. In fractures of the scapula the conditions are often so obscure that without skiagraphy the true nature of the injury may be veiled ; for instance, when disloca- tion of the humerus is combined with fracture of the acromion. In fractures of the humeriis it is the shoulder-joint and elbow-joint that require the use of the rays most frequently. Especially in reference to the elbow-joint, it may be safely asserted that an exact diagnosis with- out skiagraphy is simply impossible in by far the great majority of cases. Skiagraphy will infallibly demon- strate the various types of elbow-fractures ; it will, fur- thermore, show whether the line of fracture is transverse or T-shaped, and whether there are any complications, such, for instance, as a fracture of the olecranon com- bined with dislocation of the radius. 14 INTRODUCTION. In fractures of the forearm it is the elbow-joint and the wrist-joint that especially require the use of these rays. In these cases as well as in those previously noted a large number of new facts have been revealed, which have entirely revolutionized our pathologic and thera- peutic views. Fractures of the bones of the hand occur much more frequently than was formerly supposed. Fractures of the individual carpal and metacarpal bones, and even of the phalanges, were often mistaken for contusions. Fractures of the pelvis, the accurate recognition of which formerly offered the greatest difficulties, can also be readily demonstrated — the differentiation between contusion, fracture of the acetabulum or of the neck of the femur, and dislocation especially coming into ques- tion. Most valuable information can also be obtained as to the presence of impaction. In fracture of the femur it is not only the hip-joint that may require the use of the rays, but also the shaft and the lower end of the bone. In the neighbor- hood of the knee-joint rapid swelling often absolutely prevents an accurate diagnosis except when the rays are employed. Furthermore, in all the different intra- articular complications the occurrence of epiphyseal separation, and the question as to the transverse or oblique or T-shaped line of fracture can easily be settled. Fracture of the patella can easily be recognized with- out the aid of the rays. Still, there are some impor- tant questions — for instance, as to whether the fracture is complete or incomplete, or whether there are several fracture-lines — that could not be determined without the aid of the rays. It goes without saying that in the proper determination of the after-treatment, in the cor- INTRODUCTION. I 5 rect restoration of the fragments, and in the confirma- tion of the result in the event of wiring, skiagraphic control is simply indispensable. In fracture of the leg the difficulties were often in- superable before the discovery of the rays. It is especially in the malleolar type that serious distur- bances are observed. Especially in regard to the so- called Pott's fracture, many fresh facts were revealed by the rays, so that, just as in fracture of the lower end of the radius, our former views have been changed completely. The number of fractures of the ankle treated as sprains and dislocations, to the great disadvantage of the patient as well as of the surgeon, is legion. Fracture of the foot is also found to be more frequent than was formerly supposed. Individual fractures of the tarsal and metatarsal bones and of the phalanges were often erroneously taken for contusions. Stechow has found that the so-called edema of the foot, so fre- quently found among the German infantry, is always due to a badly united fracture of a metatarsal bone. In fracture of the ribs and of the sternum skiagraphy will often prove to be useful from the standpoint of jurisprudence. In fracture of the vertebra the exact location of the fragments is of great importance in determining the advisability of operating. In fractures of the skull, those of the face and of the inferior maxilla have derived the most benefit from the rays. Fractures of the base are still with difficulty demonstrated. In fracture of the larynx the question of differentia- tion is easily settled by the rays. PART I. FRACTURES IN GENERAL. CLASSIFICATION OF FRACTURES. A fracture (a word derived from the Latin fran- gere, "to break") is a solution in the continuity of a bone. It is either traumatic — that is to say, produced by violence — or spontaneous, caused by disease. Spontaneous fractures may occur on account of a pathologic fragility of the bones (osteopsathyrosis), which may be due to tumors (enchondroma, sarcoma, metastatic carcinoma, echinococcus cysts, etc.), or to inflammatory processes (caries, osteomyelitic necrosis, osteosarcoma, rachitis, etc.), or to constihitional dis- eases, such as syphilis and scurvy. Other cases are caused by disturbances of nutrition of the bones. Spinal diseases — syringomyelia, tabes — are also occasional causes. In this book the traumatic fractures of healthy bones will alone be considered. Traumatic fractures are either direct or indirect. A direct fracture is one occurring at that point of the bone to which a force has been applied. It is obvious that this type bears a more serious character than one caused by indirect violence, since an injury 2 17 1 8 FRACTURES IN GENERAL. to the soft tissues covering the point of fracture is added. An indirect fracture is one that occurs at a point distant from that where the force has been applied. A good example is a fracture of the lower end of the humerus produced by a fall upon the hand. Sometimes a fracture is caused by muscular contrac- tion. The seats of predilection for this variety are the olecranon, humerus, clavicle, os calcis, tibia, patella, and femur. Traumatic fractures are also divided into simple and compound. In simple fractures the bone is broken at one point, and no communication with the external air exists {subcutaneous) . In compound fractures the bone is broken at one or more points and communication with the external air exists. According to the degree of separation in the con- tinuity of the bone, distinction has also to be made between complete and incomplete fractures. According to the direction of the fracture, complete fractures are either transverse, oblique, longitudinal or spiral. Thus, according to the displacement taking place after the fracture is sustained, four different types of a complete fracture may be noted : viz. — i. Lateral displacement, characterized by the line of separation being at a right angle to the long axis of the bone (rare in adults). (Fig. 92.) 2. Axial displacement, in which the line of separa- tion is at an acute angle to the long axis. (Fig. 89.) 3. Longitudinal displacement, when the separation- CLASSIFICATION OF FRACTURES. I 9 line is parallel to the long axis. If there is axial dis- placement the so-called riding of the fragments takes place. It is often observed in fractures at the upper third of the femur. (Figs. 112, 114.) 4. Peripheral displacement, in which the fragment is turned around the long axis of the bone (torsion). (This variety may occur when the body is turned while the extremity is fixed.) If in a complete fracture small bone-fragments are either partly or totally severed from the bone, it is called a comminuted fracture. (Fig. 136.) If the bone is broken at several points, it becomes a multiple fracture. (Fig. 40.) If a fragment consisting of compact bone is forced into the substance of a cancellated one, an impacted fracture is produced. (Fig. 107.) If the fracture is caused by a bullet, it is called a gunshot fracture. The bullet of the army weapon known as the Krag-Jorgensen rifle produces extensive splintering of the diaphysis of the long bones up to a distance of 800 yards. (Fig. 1 36.) This type of fracture may also be incomplete. In incomplete fractures, which are mostly observed in very flexible bones, the convex corticalis yields and tears, while the concave stratum is only bent. This injury is called infraction (Figs. 92, 137); it maybe compared to the bending and partial splintering of a green stick, and is mainly observed in childhood. Its predilection is for the deformed legs of rachitic chil- dren, but it may occur in old individuals, where senile atrophy has caused a diminution of the organic sub- stance of the bones. It is also found, as a result of abnormal uterine contractions, as an intrauterine frac- 20 FRACTURES IN GENERAL. ture. There may be only a linear division, without any displacement or disfiguration of the external shape of the bone ( fissure). (See Figs, i and 2.) This variety is Fig. I. — Intrauterine fracture of radius and ulna (outer view). Fig. 2. — Intrauterine fracture of radius and ulna. Skiagram taken four weeks after birth. observed in the cortex and at the base of the skull ; in the superior maxilla and the scapula ; seldom in the long bones. STATISTICS. Statistics show that fractures of the bones of the extremities, including those of the clavicle, represent three-fourths, while those of the bones of the trunk comprise but one-sixth, and those of the skull but one- twenty-fifth, of all fractures. SIGNS OF FRACTURES. 2 1 Fractures of the upper extremities are twice as fre- quent as those of the lower. Most frequent are the fractures of the forearm, iS per cent. ; then follow those of the leer, of the ribs, and of the clavicle, i z per cent. ; hand, 1 1 per cent. ; humerus, 7 per cent. ; femur, 6 per cent. ; foot, 2.6 per cent. ; face, 2.4 per cent. ; skull, 1.4 per cent. ; patella, 1.3 per cent. ; scap- ula, spinal column, and pelvis, less than 1 per cent. ; sternum, o. 1 per cent. Most fractures occur between the thirtieth and fortieth years. Fractures are four and a half times more frequent in men than in women. SIGNS OF FRACTURES. The symptoms of a fracture are represented by a chain of mechanical disturbances, set up by the solu- tion of the continuity of the bone. The most impor- tant of these are abnormal mobility, crepitus, functional disability, deformity, ecchymosis, and pain. 1. Abnormal mobility is the most characteristic sign of the presence of a fracture. It is absent in the incomplete variety (fissures, infractions, etc.; see Figs. 92, 137), and also in impacted fractures — for example, in impacted fracture of the neck of the femur. (See Fig. 107.) In fractures of the ribs and the short bones unnatural mobility is also often looked for in vain. 2. Crepitus is the peculiar sensation felt when fric- tion is caused between the two separated bone-frag- ments. Crepitus is, of course, absent when there is no abnormal mobility, since the production of the characteristic friction presupposes the mobility of the fragments. Consequently, also, there is no crepitus in 2 2 FRACTURES IN GENERAL. fissures and infractions (green-stick fractures), nor in impacted fractures. Crepitus is also absent in cases of the wide separation of the fragments, whether this be caused by diastasis (fracture of patella or ole- cranon), or by the interposition of fascia or muscular tissue between the displaced fragments. These cir- cumstances will prevent mutual contact between the ends of the fragments. In other cases the fragments overlap each other to such an extent that contact be- tween the broken ends is impossible (longitudinal dis- placement ; compare p. iS), or sharp and displaced bone-fragments are driven into the muscular tissue, so that thus an interposition of soft tissues between the broken ends of the bones is produced. 3. Functional disability is seldom absent. Its extent naturally depends upon the shape and kind of the bone as well as of the fracture. This is shown in the cases illustrated by figures 72 and 123. There are individuals inured to pain who are able to use their arms notwithstanding the fracture of both radii, or who are able to walk a short distance in spite of having sustained a malleolar fracture ; but such occurrences are to be regarded as very exceptional. Still, from a legal point of view the knowledge of such possibilities is of the utmost importance. 4. Deformity is present in those fractures wherein more or less displacement of the fragments has taken place. Consequently, it will not often occur in cases of fissure or in infractions ; in other words, in fractures where neither abnormal mobility nor crepitus is to be found. Thus it can be seen that the three important signs, abnormal mobility, crepitus, and deformity, usually go DIAGNOSIS. 23 together. It must be added that wherever deformity indicates more or less displacement, shortening of the broken bone is seldom missed. 5. Ecchymosis is naturally most marked in direct fractures. It is produced by the laceration of small blood-vessels and of the medulla of the bone. If the fracture extends into the joint, there is always an extra- vasation of blood within the joint (hemarthrosis). Ecchymosis is generally more marked a few days after the injury is sustained. 6. Localized pain is a constant symptom of frac- ture. It is increased by pressure and by every active or passive effort that displaces the fragments. DIAGNOSIS. In most cases the presence of a fracture can be rec- ognized even by simple inspection. (Compare Fig. 33.) If the trifolium — abnormal mobility, crepitus, and displacement — is present, the proof of fracture is estab- lished beyond doubt. The value of inspection should not be underestimated. In fact, the part should be in- spected very thoroughly before palpation is resorted to. The custom of handling an injured organ by pressing, turning, and squeezing before it is carefully looked at can not be condemned too strongly. It pays very well to inspect the injured area for some length of time, and to compare it with the normal outlines of the opposite side, until there is a clear idea of the con- dition of things in the examiner's mind. But if there be an infraction or a fissure or an im- pacted fracture, or in cases where one of two parallel 24 FRACTURES IN GENERAL. bones is fractured (forearm, for instance; see Fig. 60), or if the break has occurred near a joint, or if there be extensive inflammation, the diagnosis may be very dif- ficult, and the injury may be mistaken for a contusion or a distortion, or even a dislocation. As to dislocation, it should be borne in mind that this injury does not lead to any abnormal mobility nor any shortening of the bone-shaft. In contusions the absence of abnormal mobility, crepi- tus, displacement, and shortening will be observed. It is obvious that these differential points are mainly to be elicited by manual examination. This process being always productive of more or less pain, it should be performed with a great deal of care. While it is often possible to diagnosticate the presence of a fracture by means of careful palpation, conclusions as to its direc- tion and as to the size of the broken fragments could seldom be drawn in the pre-R6ntgenian era unless the patient was anesthetized. If there be abnormal mobility, manual examination will naturally yield crepitus also. Whether or not there is shortening of the limb can be ascertained by measurement. It must be borne in mind, however, that the points from which measuring with a tape are begun fail to show mathematic exact- ness and regularity. They are represented by round- shaped bony protuberances, like the anterior superior spine of the ilium, the major trochanter or the external condyle of the femur, the external malleolus of the fibula, the styloid process of the radius, and the olec- ranon and acromion in the upper extremity. This variation in position of the points of measure- ment explains why an error to the extent of a whole inch can easily be made. With the employment of all DIAGNOSIS. 25 these means, fractures have often failed to be correctly diagnosticated even by the greatest surgical masters of all centuries. The courts can show endless his- tories of grave errors committed to the detriment of poor patients and not the less of poor practitioners. But the discovery of Wilhelm Conrad Rontgen has come to do away with all this. At present there are no fractures the character of which can not be estab- lished beyond a doubt. But much more has been shown to us by these rays. A glance at the fluoro- scope not only gives one an idea of the special type of the fracture, but the situation, shape, and the number of the fragments and their correlation can be clearly ascertained. The photographic plate fixes the details of the fracture exactly, and permits of the thorough study of the various features of the fracture type. Its comparison with the normal skeleton makes the abnormalities evident at once, so the use of anesthetics, which in many cases are not at all advan- tageous for the patient's physical condition, is no longer required in diagnosis. It is clearly seen that the advent of the Rontgen rays has accomplished no less than a revolution in the understanding of frac- tures. On account of their special importance, the diagnostic use of skiagraphy is considered in a sepa- rate section. 2 6 FRACTURES IN GENERAL. THE PROCESS OF REPAIR AND THE FORMATION OF CALLUS. Repair of simple subcutaneous fractures generally takes place without any constitutional disturbance. The course being an aseptic one, fever, as a rule, is absent. When there is much extravasation, infiltra- tion, or destruction of tissue, the lively absorption of blood-ferment may cause slight and transient elevation of temperature (up to 101.5 F.) {aseptic absorption- fever). Microscopic examination of the urine shows, with few exceptions, for the first four or five days following the injury, cylindric elements, brownish clots, and the relics of shrunken blood-corpuscles. Traces of albu- min are also often found in the urine. Fat is absorbed from the shattered medulla of the bone by the lymph- vessels, and gains access thereby to the blood-circula- tion, from which it is generally excreted slowly without causing any disturbance. In the urine its presence is also not infrequently demonstrated. In cases of ex- tensive shattering, however, or in multiple fractures, an abundance of fat accumulated in the circulation is sometimes caused, which may lead to fat embolism. In this extremely grave condition, which is nearly always fatal, there is in the capillaries a conflux of fat- globules, which causes the obstruction of numerous capillary channels by cylindric masses of fat. This occurs especially in the lungs. The blood-vessels that are incarcerated between these masses are compelled by pressure to give their serum away to the lung tissue, so that edema of the lungs is produced. The symptoms of this condition are those of shock ; FRACTURE-REPAIR AND CALLUS-FORMATION. 2J they never appear as a primary shock occurring- imme- diately after the injury was sustained, but manifest themselves, as a rule, on the third, or sometimes even on the fourth or fifth, day. Owing to the edematous condition of the lungs, dyspnea, combined with cardiac irregularity, naturally is a prominent symptom. The swelling of the soft tissues in the immediate vicinity of the fracture is caused by extravasation and edema, the latter being produced by a slight degree of inflammation. The swelling generally disappears by absorption in the course of the first week. The integument, which had been overextended by the swell- ing, becomes flabby, and at the same time loses its original bluish-black discoloration and shows the char- acteristic rainbow tints. Formation of Callus. — Hand in hand with the absorption process goes the formation of a new bone- tissue, called callus, which originates between and around the broken ends and gradually fills up the separation line, thus restoring the continuity of the broken bone. , Most of the callus is formed from the inner strata of the periosteum, while the medullary tissue furnishes the rest. The first indication of the healing process is the occurrence of a periosteal swelling [periostitis ossificans), which is caused by the proliferation of the osteoblastic cells, between which lime-salts are deposited. (Fig. 3.) Lacerated portions of the periosteum are scattered around the fracture area and form another starting-point for peripheral growth. The processes of cell-proliferation and calcification of the young tissue begins simultaneously from the medullary canal and Haversian channels. Afterward Osteoblasts. Newly formed bone. Old bone. Fig. 3. — Osteoblasts on old bone. Fig, 4. — Longitudinal section through a fractured fibula in a young adult (two weeks after' the injury): a, Fatty medulla; b, myelogenous bone-tra- beculte; c, corticalis ; (//myelogenous trabecule, consisting of osteoblasts and osteoid tissue ; e, connective tissue between the fragments ; /, newly formed car- tilage ; g, fragment separated from the fibula; h, osteoblasts; i, periosteal osteo- phytes. 2S FRACTURE-REPAIR AXD CALLUS-FORMATION. 29 the periosteal and medullary calluses join within the separation line, so that the bone-ends are surrounded exteriorly by a broad ring, while interiorly, or within the medullary canal, they are fastened by a plug of young bone-tissue. (Fig. 4.) A conception of the progress of this formation can be gained by palpation, which reveals a spindle-shaped thickening of a slightly cartilaginous character around the line of bone separa- tion. (Compare Fig. 1 13.) A few weeks after the in- jury, when the formation of the external ring (periosteal callus) and of the internal plug (medullary callus) is com- pleted, the periosteal swelling subsides also, the callus becomes solid, and mobility ceases to be observable. The length of time necessary for perfect consolidation varies between two and twelve weeks, according to the size of the bones. From the statistics of E. Gurlt it is learned that perfect consolidation of complete subcu- taneous fractures requires for — Metacarpal or metatarsal bones, as well as ribs 3 weeks. Clavicle 4 " Forearm 5 " Humerus and fibula 6 " Surgical necks of humerus, and tibia 7 " Tibia and fibula together 8 " Femur 10 " Neck of femur 12 " For some time after this complete consolidation has taken place the anatomic condition of the callus by no means remains unchanged. Years may elapse before the original callus-tissue is completely absorbed and the regular bone-system with the normal medullary canal is reestablished, as is easily proved by the Rontgen rays. According to the degree of displace- 30 FRACTURES IN GENERAL. ment there is abundant callus proliferation, so that sometimes enormous masses are thrown out, and may be mistaken for regular osteomas. In children, in whom there is frequently but little periosteal lacera- tion, there is sometimes so little callus formation that even the Rontgen rays disclose but a very thin line of separation. In such cases the evidence of a frac- ture may not be proved by the rays two months after the injury was sustained. (Fig. 137.) Since aseptic treatment has brought the mortality of compound fracture from 45 per cent, down to nearly nil, the consolidation of fragments in this condition, formerly so much dreaded, generally takes place with- out inflammatory reaction, or with very little. Even in pre-antiseptic times such consolidation was occasionally observed in one class of compound frac- tures : namely, gunshot wounds. In compound fractures necrosis of one or both bone-ends sometimes occurs. This is caused by the detachment of periosteum, so that the vascular supply is diminished. A line of demarcation usually forms between the normal and the necrosed tissue ; and in be- tween two and six months after this the necrotic bone exfoliates. Meanwhile the ossifying inflammation of the periosteum creates abundant bone-substance, so that enough material for thorough consolidation is furnished. Sometimes callus formation is late. Among all frac- tures, that of the upper third of the humerus shows the greatest tendency for late union. The cause for this condition can but seldom be elicited. Syphilis, scurvy, rickets, malignant bone-disease, and paralysis are gen- erally held responsible for it. DISTURBANCES IN THE PROCESS OF REPAIR. 3 1 DISTURBANCES IN THE PROCESS OF REPAIR. One of the most distressing" disturbances in the healing process of fractured bones is the failure of the occurrence of bony union between the broken ends, the consequence of which is the formation of a new false joint (pseudarthrosis). Pseudarthrosis is either called fibrous, in which case the only junction between the fragments consists of fibrous tissue, or real, when there is the formation of a true joint-capsule, the latter condition being extremely rare. (Fig. 135.) Excep- tionally, however, a synovial membrane and synovia are formed. It is self-evident that in either event, whether there follows either a fibrous or a true pseud- arthrosis, the bone-ends remain movable. The causes of false mobility may be either local or constitittiojial. Late necrosis of the callus, caused by inflammation and suppurative infection from a focus (furuncle, tonsillitis), even in simple subcutaneous fractures, and especially in the extensive crushing of the broken area, so often produced by compound frac- tures, favors its formation. Scant callus formation, which, as before stated, often delays union, may also be responsible for pseudarthrosis. Interposition of soft tissues (muscle, fascia, and ten- don) produces pseudarthrosis with absolute certainty. This intervention is most frequently observed in the humerus and the femur, a fact which is explained by the great tendency to extensive displacement mani- fested in these long bones. In these cases thick masses of surrounding muscle are easily pushed be- tween the fragments. As before mentioned, overrid- 32 FRACTURES IN GENERAL. ing of the fragments may produce pseudarthrosis, even if there be profuse callus formation. The constitutional causes favoring non-union are the same as those that cause late union. Pseudarthrosis takes place in about i in 400 fracture cases. Gangrene may be the result of a mechanical or of a traumatic cause. The application of too tight a splint is a well-known and most deplorable mechanical cause of gangrene. Extensive pulping or laceration of soft tissues or the rupture of a large blood-vessel, often caused by a crush or by sharp bone- fragments, may lead to extensive blood-extravasation, which is liable to result in gangrene. It hardly needs to be stated that these lesions are of a severe character. The anterior and posterior tibial arteries are those most frequently observed to become ruptured in this manner. The same causes may sometimes produce aneu- rysm. A mechanical insult to a nerve situated at the point of a fracture may also lead to a series of complications. There may be a direct injury done to a nerve, as, for instance, to the radial or peroneal nerve ; or a perfora- tion by a bone-splinter (interposition of the nerve) of the nerve that rests directly upon the bone. (Fig. 66.) In other cases pressure conveyed to the nerve by exuberant callus proliferation (Fig. 67) produces loss of sensation or motion, or of both. If the paralytic symptoms appear slowly and gradually, it may be regarded as an absolute pathognomonic sign that the nerve-pressure is clue to exuberant callus formation. Embolism and thrombosis are very rare occur- rences in subcutaneous fractures. These conditions are mostly observed in fractures of the bones of the lower extremity. Their cause is the formation of a blood-clot, induced by the trauma of a vein. From the clot obstructing the vein (thrombosis) an embolus may originate, which, after being torn away, may reach the pulmonary artery ; and sudden death may follow the plugging of this artery. The signs that foretell this fatal occurrence are sudden suffocation, cyanosis, dysp- nea, and an imperceptible pulse. There are, however, a few cases on record in which, in spite of the marked development of the clinical symptoms of this grave con- dition, recovery has taken place. Ankylosis (from ayxokoq, "angular, crooked") may be bony or fibrous. Bony ankylosis maybe originated by a direct fracture into a joint, followed by an inflam- matory process, which in the course of time unites the bone-fragments among themselves within the joint. (See Fig. 1 18.) Fibrous ankylosis may be caused by an inflammatory process in the joint. This may have been produced by some condition such as a profuse hemorrhage into the joint, leading to synovitis or arthritis, from which adhesions within the joint may follow. Hematoma, if not absorbed, may also lead to serous or purulent teno- synovitis. If plastic inflammation is set up in the sheath of a tendon in the vicinity of a joint, stiffness of the joint may result (tenogenous ankylosis). This is especially observed in non-reduced fractures of the lower end of the radius. Prolonged immobilization also sometimes pro- duces mild forms of fibrous ankylosis. Atrophy is nearly always caused by prolonged inac- tivity of the muscles. But, in the course of time, it will affect not only the muscles, but also the tendons. Just 34 FRACTURES IN GENERAL. as a sword becomes so rusty in its scabbard that it can not be drawn, so may a tendon become adherent to its sheath, if it be not frequently moved to and fro. Motion induces the secretion of the synovia in the ten- don-sheath and thereby keeps up the possibility of the smooth gliding of the tendon therein. Delirium tremens is a not infrequent and often a fatal complication. It is characterized by the violent inclinations of the patient, the presence of delusions, and the entire absence of fever. An alcoholic history will but seldom be absent. Pneumonia is provoked by prolonged dorsal de- cubitus (hypostatic), and is especially apt to occur in alcoholics and old patients. In summing up it can readily be seen that if the causes of the disturbances in the process of repair be analyzed thoroughly, it will be found that, except in a few cases, the ill results specified can be avoided by carefully controlling the course of a fracture. Since asepsis began its triumphant march the evil conse- quences of even compound fractures have been reduced to a minimum. (Compare p. 51.) Life is generally only endangered nowadays when organs of vital importance, such as the brain, spine, lungs, or pelvic viscera, are injured. TREATMENT. The laws that govern the treatment of fractures are determined by a correct diagnosis. In fact, the princi- ples of treatment are reduced to a few points of simple common sense as soon as there is a complete and cor- rect diagnosis. TREATMENT. 35 Simple subcutaneous fractures showing but little or no displacement often heal without any, or in spite of any, treatment, as the long sin-register of quackery demonstrates; and the number of fractures not recog- nized as such during treatment is legion. The first object of a rational therapy is the consoli- dation of the fractured ends without any displacement and without injuring the adjacent tissues or the func- tion of the limb. It is evident that if there is no dis- placement, no replacement (or, better said, no reposi- tion) will be necessary. All that is required then is to protect the injured limb in its normal position. This is done by proper immobilization. In the great majority of cases, however, more or less displacement of fragments follows the fracture. In such an event, of course, the displaced fragments must be reduced to their normal position. After exact reposi- tion has been attained, proper fixation in the normal position is in order. These doctrines are so simple that it seems almost unnecessary to repeat them. And yet they are vio- lated frequently. The functional impairment following some fractures, especially the formation of adhesions in the vicinity of joints, has led a number of surgeons to enunciate this dogma : " The most important part in the treatment of fracture is the treatment of the soft tissues." They claim, in other words, that because the function of the soft tissues — for instance, of the tendons — is impaired after a non-reduced fracture, the soft tissues should have received more attention, in- stead of the displaced fragment having simply been reduced to where it belongs. Nothing, in fact, is more contrary to common sense than this dangerous maxim, 3 6 FRACTURES IN GENERAL. which is based upon correct observation, but incorrect interpretation. It should always be considered that the relations of the soft tissues to the bones are like that of the clinging- vine to the sturdy oak. Galen says that the bones give the human body form, erectness, and firmness. It is evident that an injury of the bones impairs these three fundamental factors. The most important step toward repair must thus be taken in the foundations rather than in the superimposed structure. If there is displacement of the bone-fragments, un- due pressure must necessarily be made upon the soft tissues ; non-reduction means persistence of pressure, the fatal consequences of which are well known. Reduction means the relief of pressure. Of course, the act of in- jury can not be undone by the mere cessation of pres- sure ; but the influence of the injury on the soft tissues — the influence of the pressure, in fact — lasts only a short time and is insignificant after early reduction ; there is then but little inflammation, and consequently little exudation, and therefore repair is easy. This means that the premises of adhesion-formation are wanting. And clinical observation shows that if there was per- fect reposition, the joints as well as the sheaths of the tendons are found free, provided the immobilization has not lasted for an extraordinary length of time. To accomplish exact reposition, it is desirable to have the assistance of one or two persons, who should make extensive counterextension while the surgeon replaces the displaced fragments. In fractures of the bones of the upper extremity assistance can be dis- pensed with, but in those of the lower extremity proper reposition is hardly possible without the assist- TREATMENT. $*] ance of at least one person. If the exact situation of the fragments has been ascertained (and this can always be done), the surgeon should know at once how to replace them to their former — that is, to their normal — position. This is done by making manipu- lations either in the way of pressing sideward and turning one of the fragments, or by putting the limb into a proper angle, and thus correcting the abnormal direction. Whenever the fragments can be seized by the sur- geon's fingers reduction will be found easy ; but if their manipulation is difficult, anesthesia is to be em- ployed. If the surgeon is undecided as to whether he should administer an anesthetic, he should give the benefit of the doubt to the anesthesia. Reduction is especially difficult where there is extensive displace- ment of the fragments, or if their sharp edges have pierced the sott tissues, or if muscular tissue inter- venes, or in the rare event of simultaneous dislocation. But all these conditions can easily be ascertained by the Rontgen rays, and under their guidance reposition will always be successful. If a fracture has been sustained in the street, some kind of improvised splint should be applied, and no re- duction should be tried before the patient has reached his home ; but as soon as he has arrived there, reposi- tion should be undertaken at once, since the whole course of recovery might be jeopardized by delaying this most important procedure. If the upper extremity is concerned, the surgeon may seize each fragment with one hand, and by pull- ing and counterpulling the fragments are slowly put into their normal position. 38 FRACTURES IN GENERAL. In fractures of the bones of the lower extremity the patient should be placed upon a firm bed. Clothing, shoes, etc., in the vicinity of the fracture should be cut off, to avoid any unnecessary manipulation of the broken area. The limb must be carefully lifted, con- stant extension being exercised at the same time. The pelvis must be immobilized, which is best accomplished by one assistant putting his hands on the crests of the ilia and pressing the pelvis down upon a tight underlayer ; or the pelvis may be drawn upward by slinging a long towel around the perineum. The surgeon should now seize the patient's foot on the heel with his left and on the metatarsus with his right hand, while he pulls. When he has lifted the foot to the horizontal position, the fragments are care- fully turned to and fro, according to the direction of the displacement, until the tip of the foot, the interior margin of the patella, and the anterior superior spine of the os ilii are in a straight line. If two assistants can be obtained, they can make extensive counterextension, and the surgeon may then reduce the displaced fragments by simply pushing them into their proper positions. If extravasation be exceptionally profuse, punctur- ing or massage treatment should be employed until it becomes possible to grasp and reduce the displaced fragments. (As to the technic of puncture, see the section on the Treatment of Patellar Fracture.) After reposition is accomplished, immobilization of the reduced fragments must be secured in order to retain them in their proper place. For this purpose the broken bone-ends as well as the adjoining joints must be surrounded with suitable apparatus in the TREATMENT. 39 shape of splints and bandages. If nothing else be at hand, shutters, pillows, or similar improvised contriv- ances may be utilized. On the battle-field bayonets, sabers and their scab- bards, muskets, etc., may serve as temporary splints. The thorax may act as a splint for a broken arm, if necessary, the arm being fixed upon it. In like man- ner a broken leg may be fixed upon the sound one. Fixed Dressings. — As soon as reposition has been perfected, fixed dressings (splints, plaster-of- Paris, etc.) should be employed for the purpose of retaining the fragments in their proper positions. In case complete reduction can not be accomplished at once, extension dressings are preferable. All fixed dressings require an underlayer, consisting of cotton, flannel, or muslin, in order to avoid pres- sure upon the swollen area and at the same time to prevent the hairs of the skin from adhering to the dressing. It is a matter of skill and experience to apply a dressing tight enough to render shifting of the frag- ments impossible, and, on the other hand, to apply it so smoothly that there is no pressure. Gangrene of that portion of the skin resting directly upon a bone- protuberance is easily produced even by a moderate amount of pressure. It is wise, therefore, to pad such dangerous areas profusely. Venous stasis and edema, finally leading to necrosis, may be caused by too tight an application of a simple bandage. To avoid such possibilities it is advisable, in all fixed dressings, to leave fingers and toes always uncovered, so as to have permanent control. No dressing accomplishes the purpose of retaining 4-0 FRACTURES IN GENERAL. the fragments better than pi aster-of- Paris, since it adapts itself to the contours of the body in an admir- able manner, and surrounds it at the same time like a coat of mail. The best quality is not too good for use in a surgical dressing. The extra-calcined variety (CaS0 4 2H 2 0), such as is used by dentists, is consid- ered the best. Good plaster must set quickly and firmly ; in fact, it must become hard in about a minute after the dressing is complete. In making plaster-of-Paris bandages the following points should be observed : The plaster-of-Paris is dusted over a crinoline bandage about five yards long and from two to four inches wide. The bandage is best laid upon a table and the plaster rubbed well into its meshes, where it is evenly distributed. After thorough impregnation it is rolled up loosely and stored in an air-tight can until needed. When used, the plaster bandage is immersed in luke- warm water until bubbles cease to come up, which fact announces its being thoroughly soaked. Then the bandage is squeezed out well and evenly and is firmly applied. Reverses must be avoided. To give the dressing a nice appearance, some dry plaster may be moistened well with water until the consistence of thick cream is obtained. This paste is then evenly rubbed over the surface of the dressing. If there are small wounds present that require an aseptic dressing, a small opening (fenestra) should be made over them. If they are covered with a small glass or bottle or ointment-pot while the bandages are being applied, these points can easily be kept open. (Fig. 5.) The fenestral margins are best surrounded by absorbent cotton, which may be fastened to the integu- TREATMENT. 41 ment by collodion. At the knees, the groin, etc., it is necessary to strengthen the fenestral margins by laying small wooden splints so as to prevent breakage of the dressing. To preserve the plaster dressing against moisture (a femoral dressing in a child will surely be destroyed if Fig. 5.— Fenestrated plaster-of-Paris dressing (for. wound-treatment). moistened with urine), it should be painted with copal varnish. (See Fig. 115.) The taking-off of a plaster dressing is generally more troublesome than its application. The best instrument for the purpose is a circular saw provided with a beak. If this instrument is not at hand, a grooved line, into which salt water or, preferably, vinegar is poured, is scratched into the plaster. This will facilitate cutting through the plaster layer alongside this marked line. 42 FRACTURES IN GENERAL. During the last few years — thanks to the impetus of Hessing, the ingenious mechanician — the application of plaster dressings, especially to the lower extremity, immediately after the fracture is sustained has been highly recommended by F. Krause, Korsch, Albers, and others. (Fig. 6.) In many instances the patients have been permitted to go about after an interval of a day or two. Ambulatory Dressing. — The advantages of this am- bulatory dressing are obvious. Atrophy of the mus- cles is surely avoided, as their functions are not inter- rupted. Late union or non-union does not occur, if this method is employed, since callus formation is abundant. Hypostatic pneumonia, so dangerous in aged people, is absolutely excluded. There is also much less tendency to delirium tremens. It hardly needs to be mentioned that this form of treatment adds considerably to the patient's comfort. In supramalleolar fracture, or that of the head of the tibia and the femoral condyles, and in fractures of the femur, the pelvis may serve as a point of support. The sole portion of the dressing is made especially strong, to permit of stepping upon it. At first the patients are allowed to move only in a go-cart. But these advantages are fairly offset by the im- mense difficulty in keeping the treatment under perma- nent control in practice. The technic of applying such dressings is complicated, and therefore is dangerous in the hands of the inexperienced. In hospital practice, where continuous control is possible, the adoption of this method in many instances proves to be of great value. So, while this treatment is undoubtedly advisable in cases in which the dressing can be removed any TREATMENT. 43 moment, in case ischemic symptoms should manifest themselves, it should not be recommended for adop- tion in general practice. Proper individualization, based on sound judgment and experience, should Fig. 6. — Ambulatory dressing. fix the limits to its applicability. Here, as in many other instances, the golden mean should be chosen. The writer has often found it useful to permit his patients to walk about as soon as the swelling had 44 FRACTURES IN GENERAL. subsided, under die protection of a well-padded and carefully applied plaster-of-Paris dressing. In the hospital service of the writer this stage was generally reached after the elapse of a week. Some- times slight edema was set up at first ; then the patient was directed to lie down at once, and his lower ex- tremity was vertically suspended until the swelling had disappeared. In private practice it is not advisable to start the patient to walking before at least two weeks have elapsed. When a circular plaster-of-Paris dressing is applied, it will often be found desirable to utilize it as a splint after carefully taking it off. In these cases the under- layer of the dressings should consist of muslin only, and the bandages should be applied as firmly as pos- sible. As soon as hardened, the dressing is cut through alongside a straight line, which has previously been marked with a pencil. To avoid injury of the skin while cutting the dressing, it is advisable to pro- tect the area below the mark with strips of pasteboard or of thin board. After the dressing is carefully removed, it can be lined with tricot and provided with strips. Molded plaster splints can be made of bunches of hemp, flax, jute, or straw that have been immersed in a thin paste of plaster. After being soaked there the fibers are applied to the part, where they are held by the turns of a wet bandage. The part has first to be protected by oiling. (Figs. 7, 8, and 9.) These removable splints are particularly serviceable in the treatment of compound fractures. (See p. 67.) A special splint of this kind, most useful in fractures of the humerus, is the collar splint (Fig. 7), which is TREATMENT. 45 made by rolling- the plaster bandages up and down in a longitudinal direction, covering the metacarpus, the dorsum of the hand, and the extensor portion of the arm to the shoulder and the middle of the neck. About eight bandage strips are required for this pur- pose. When the layers are thick enough, the neck portion is reversed outwardly. Thus a support is gained for a bandage, which runs from this improvised collar down to the axilla of the opposite side. In Fig. 7. — Collar splint. the same manner the splint is fastened to the arm. (Fig. 8.) If suspension of a limb in a splint should be consid- ered, hooks or loops of wire may be inserted. (Fig. 9.) The interrupted plaster-of- Paris dressing, in pre- antiseptic times so very much en vogue, is almost entirely abandoned now, since wound dressings nowa- days need to be changed but rarely. It is only in cases of sepsis and joint suppuration that they are 4 6 FRACTURES IN GENERAL. used, in order to permit of frequent changes of the wound dressing without causing the patient much discomfort. In this method of dressing the wound area is overbridged on two sides by a strong rod of iron, the straight ends of which are incorporated in the Fig. 8. — Collar splint superficially fastened in fracture of the humerus. plaster-of Paris dressing, while bent loops leave the wound area free for the application of the wound dressing-. As a substitute for plaster-of-Paris, silicate of potas- sium is sometimes used (so-called sodium dressing). Its advantages are its cheapness and lightness ; its TREATMENT. 47 disadvantage is that it requires twenty-four hours for becoming dry and firm. This forbids its application in fractures of recent origin, but in a later stage its employment may well be considered. The manner of application is very simple. The silicate of potassium mixture having been poured into a basin, a number of circular bandages are well soaked in it. Then the bandages are put upon the limb after the same princi- ples as are observed in applying plaster-of-Paris dress- ings. A muslin underlayer must be applied first in order to protect the integument. The only disadvantage of the plaster-of-Paris dress- ing is that if a swelling sets in underneath, the arterial Fig. 9. — Molded plaster splint for the lower extremity, ready for suspension. supply becomes limited, and the muscles lose their elasticity, and may consequently become contracted (ischemic contraction). Nerves may be injured in the same way, ischemic paralysis being then the conse- quence. Under strict hospital control such outcome need not be feared, since the dressing can be cut off as soon as the first signs of swelling are noticed. But most fractures are treated outside of the hospital, where the surgeon must rely principally upon the ini- tiative of the patient. The most unfortunate feature of such accidents is that the stronger the pressure becomes, the more the sensation stops, so that the patient is then under the fatal impression that his con- 48 FRACTURES IN GENERAL. dition has improved, and die necessary surgical inter- ference is liable to be unduly postponed. It is much safer, therefore, at least for the surgical novice, to apply splints at first, — that is, during the first week after the injury, — and then, after the swelling has almost sub- sided, to substitute a plaster-of-Paris dressing. The number of the different splints advised for the treatment of fractures is legion. There is hardly a surgeon of repute who has not devised a splint or splints of his own. Most of them are useful, but under the aep-is of a thorough diagnosis one is sur- prised to find how much he can accomplish by choos- ing the simplest forms of splints. The limits of this book forbid describing more than a few kinds. A splint consisting of simple board in most cases is just as good as any other. If lime-wood (linden or bass) can be procured, it should be preferred for this pur- pose. A splint should be well padded with muslin or flannel and should extend over the joint nearest the frac- ture on each side just the same as the plaster-of-Paris dressing. A dressing of this kind should also be changed at least once a week. When, after the elapse of a week, the swelling has subsided, the dressing becomes loose, and the fragments may easily become displaced again. Wire splints (Fig. 12), besides having the great advantage of bein^ made of a li^ht and clean material, adapt themselves easily to the contours of the body. They are especially useful in the treatment of com- pound fractures. (See p. 67.) The fiber splints, recently advised by Wiener, fur- nish a very convenient material, and the splints made of gutta-percha, porous or hatters felt, leather, cellulose, or pasteboard are also serviceable. TREATMENT. 49 Permanent extension, best known as Buck 's ex- tension, is a simple and valuable means of keeping the fragments in situ so as to overcome shortening. It is particularly used in fractures of the femur and the spine, sometimes also in fractures of the surgical neck of the humerus and of the elbow. Extension and counterextension are exerted by the use of a weight and a pulley, the counterextension being made by ele- vating the foot of the bed. (Fig. 10.) The weight must Fig. 10. — Extension dressing in fracture of the femur. be the heavier the older the individual and the greater the muscular rigidity is. It may vary from five to twenty-five pounds. If a light weight be used, the patient will stand the treatment better and longer; but if too little weight is employed, the fragments are likely to become displaced. The weight is suspended by a loop made of adhesive plaster strips, which should extend up to the fractured area. In fractures of the femur a wide adhesive plaster strip should reach as far up as to the 4 5o FRACTURES IN GENERAL. knee-joint, to take off the strain from the latter as well as to arrest motion. In order to keep the plaster off both malleoli, a board is inserted between the two adhesive plaster strips for the purpose of keeping them far asunder, so as to avoid decubitus. (Fig. 1 1). In order to obtain perfect immobilization of the lower lee and at the same time to avoid decubitus, Volkmann devised his so-called foot-board. (Fig. 11.) Fie. II- — Volkmann's foot-board. If the adhesive plaster is not well borne, a filtrated sticking substance can be sprayed over the limb by an atomizer.* Two felt strips of the width of a hand are applied in a longitudinal direction. They are fastened by circular turns of a mull bandage. To the lower ends of these felt strips a canvas strip is attached to serve as the loop for the weight. *A commendable sticking mass of this kind is: R. Cerse flavae, Resinae Dammara, Colophonii, Terebinth, . . . . 01. Terebinthinae, Alcohol, Ether, . aa 10 parts. i.oi parts. . aa 55 parts. TREATMENT. 5 I Massage is a splendid adjunct in the after-treat- ment of fractures. If there is no tendency to displace- ment, — as, for instance, in the extraarticular variety of partial fracture of the lower end of the radius, — or if small portions of the condyles are broken but still remain in contact with the bone, or if, in fracture of the patella or the olecranon, no diastasis is present, mas- sage treatment can be commenced as early as a few days after the injury. But whenever there is the slightest tendency to displacement, this treatment is not in order before thorough consolidation of the frag- ments is warranted. To substitute massage entirely for the good old immobilization-treatment, as has been advocated re- cently, is not advisable. There has lately been observable a tendency on the part of a few surgeons to treat simple subcutaneous fractures by wiring the fragments. While under the auspices of asepsis such treatment need not be followed by any reaction, and might in the hands of competent masters give excellent results in suitable cases, such tendencies must be regarded as surgical aberrations. It is only where much diastasis is present, as in frac- ture of the patella (olecranon), when bony union appears improbable, that such rigorous interference is demanded. But by our recent means of making a positive diagnosis possible in all cases it is usually just as easy to obtain a perfect result by a simple blood- less reduction and by thorough immobilization. Compound fractures have to be treated according to the principles of the aseptic wound treatment. :;: * Compare the author's " Manual on Surgical Asepsis," chap. II; W. B. Saunders, Philadelphia. 52 FRACTURES IN GENERAL. To understand asepsis we must, first of all, know the factors which may interfere with its thorough execution. They are : The instruments, the dressing- and suture material on the one hand, and, on the other, the atmos- phere and the skin of the patient and of the surgeon's hands. In reference to the first factors it can safely be maintained that ideal asepsis is now an established fact. All objects which stand boiling' well can indisputably be made sterile. This also applies to the much-disputed question of catgut, since Hofmeister has shown us by the formalin treatment how to boil this material without impairing its tensile strength. It is, of course, to be presumed that the sterilization of the material in question is supervised by the sur- geon himself. The process of sterilization must, in other words, go on in the operating room, where the sterilizers must be kept. There the towels, dressings, the suture material, etc., must be taken from the sterilizer and put directly upon the instrument table or the body of the patient. This naturally causes trouble for the surgeon, but it is an absolute necessity, in view of that fatal human characteristic — forgetful ness. The second factor, the atmosphere, seemed to have been settled by the classic experiments of Schimmel- busch, Petri, and Cleves-Symmer. But in consequence of Fluegge's investigations * this question has been re- vived recently, and it seems to have disturbed the sur- gical mind unnecessarily. Theoretically, the possibility of atmospheric infection can not be disputed; but it hardly is attainable in practice. The atmosphere, it is true, contains an enormous number of bacteria, but these being innocent mold, yeast, and fission fungi, *Fluegge, " Zeitschrift fur Hygiene," 1897, Band xxv. TREATMENT. 53 they are, fortunately, nonpathogenic for the human race. Bacteria which are pathogenic for man are present in the atmosphere only under abnormal conditions : as, for example, when they are stirred up from their natural habitat — the earth's surface or the dust of the walls, the floor, the tables, etc. The properties of the atmos- phere are, in fact, injurious to pathogenic bacteria in every respect. The atmosphere, if exceptionally visited by a vagabond pathogenic bacterium, can be only a temporary and most uncongenial halting-place for it, in which it will soon be destroyed. It is a most for- tunate feature of the pathogenic bacteria, especially the pus-producing variety, that they have a marked tendency to settle. Wherever they settle they adhere, and if they are not provoked, so to say, by being stirred up, they can not come into contact with a wound any more. According to Stern's experiments, heavy bacteria settle to the ground within the course of an hour and a half, while the lighter ones require about an hour lono-er. From these facts we learn that the bacteria-contain- ing dust in a room should not be stirred up by clean- ing and sweeping a few hours before an operation is to take place there. As moisture precipitates dust, it is advisable to saturate the air in the operating room at least during two hours before the operation. This can be done by filling the air with spray or with steam from a kettle. The windows should also be kept closed, especially if there is a current of wind directed toward them. But another possible source of infection propagated by the atmosphere deserves attention. The air ex- 54 FRACTURES IN GENERAL. pired by the healthy, according to Tyndall, does not contain bacteria, although the cavity of the mouth is a well-known gathering-place for all kinds of pathogenic as well as nonpathogenic bacteria. Staphylococci and streptococci are nearly always found. It has, however, been proved by bacteriologic tests that in healthy per- sons the virulence of these bacteria is very slight. Clinical observation is in accord with this. But if the surgeon suffers from tonsillitis or even from a rhinitis, the number as well as the virulence of his intra-oral bacteria is remarkably increased. If the sick surgeon talks and coughs a great deal while bent over the wound, there is a possibility of carrying some of these bacteria into it, especially in an operation of long dura- tion. The remedy is simple, and proves the wisdom of the old saying, " Speech is silver and silence is gold." The assistants in the operating room must be so well drilled that they understand a twinkle. Most manipu- lations can be carried out as by an automatic apparatus, without the need of saying one word. Still, if the sur- geon is very scrupulous, he would best stop perform- ing important operations until his recovery from the ailments I have mentioned. Easy as the maintenance of asepsis is in regard to the atmosphere and to all objects which stand boiling, so is it difficult in regard to the skin of the patient and the hands of the surgeon. Skin-bacteria are the stumbling-block in the way of perfect asepsis. The undeniable fact remains, that their total destruction or removal is practically impossible. The surface of the human body is impregnated with many different bacterial species. Some of them adhere to the skin surface, some are embedded in the dried TREATMENT. 55 cells of the epidermis. They are all accessible to sterilization. They do not necessarily need destruc- tion, but removal. This can be done by simple mechanical means — viz., scrubbing with soap and water. It is made so much the easier by preliminary procedures — viz., whenever possible, the patient is given a warm bath twenty-four hours before operation, the field of operation being scrubbed with green soap and shaved while the patient is in the bath. Then a poultice of ordinary green soap is applied to the skin until shortly before the operation. Thus, thorough permeation of the epidermis — the dried cells of which are, in fact, macerated by this procedure — is obtained. Areas like the perineum, and the scrotal and inguinal regions, which are particularly rich in glands, must be scrubbed with especial care. Before the operation the skin is scrubbed energetically with linen compresses which are dipped into hard fluid soap. This hard soap consists of green soap mixed with soft sand (Stuttgart sand). The scrubbing process consumes about two minutes' time, and goes on while a stream of very warm water constantly flows over the surface to be sterilized. Then thin green soap is used in the same manner and for the same length of time. Par- ticular attention is given to the folds and creases of the skin. Now the skin is dried with an aseptic towel, and rubbed for one minute with a gauze compress which is saturated with fifty per cent, alcohol. The alcohol is not regarded as a disinfectant in the proper sense, but it is mainly used for the purpose of dissolving the fat of the skin, which is a most congenial resting-place for bacteria. By dissolving their shelter the bacteria are naturally removed. 56 FRACTURES IN GENERAL. It is self-understood that the means with which asep- sis should be attained must be aseptic. This refers particularly to the water used for washing and the soap, which must have been prepared by the boiling process. If brushes are used, special care has to be taken, as they can only with difficulty be rendered aseptic, thorough cleaning impairing their usefulness. Whether alter these procedures washing with bi- chlorid of mercury or lysol or similar disinfectants is still needed is open to discussion ; it will certainly do no harm. There are other similar methods of rendering the surface of the skin sterile. If they are thoroughly mastered and carried out minutely, they may be em- ployed just as well ; but the trouble is that under- neath the skin surface a number of bacteria are shel- tered by the glands of the skin, the secretions of which offer a favorable soil for their development ; and these are not accessible to any disinfection or removal. Hence, other means have to be chosen to prevent their faculty of infection. And, in fact, they will do little harm if cared for properly. It is evident that in incising the skin the knife dis- sects a number of glands and thereby exposes the bacteria contained by these glands. This undeniable fact fully explains not only the so-called suppuration of the stitch-canals, many cases of so-called late infec- tion, and the bad reputation of the catgut, but also most of the numerous " incomprehensible " infections which develop under the supervision of the " extremely careful aseptic surgeon." Here is also the explana- tion of the suppuration occurring " in spite of the most minute aseptic precautions," which not only TREATMENT. 57 astonished many an experimenter in his laboratory, but also made him set up new surgical doctrines. I may take this opportunity to state that bacteri- ologic tests of aseptic methods, gained on artificial soil, can not be applied to biologic processes, the living cell reacting against bacteria differently from gelatin, agar, or serum. That the bacteria thus set free by the skin incision find the most liberal opportunities to come into contact with the deeper regions of the wound need not be em- phasized. Still, so far as my knowledge goes, there are no systematic precautions taken or advised in this direction. If a general can not fight the enemy suc- cessfully in the open battle-field, he tries to starve him out, or he may eventually overreach or circumvent him. And the deep-skin bacteria can also be circum- vented. Let us consider, now, that the dissecting knife com- ing into intimate contact with these deep-skin bacteria, generally represented by the staphylococcus species, must necessarily be regarded as infected. The hands of the surgeon fall under the same considerations. This indicates two necessities — in the first place the change of the infected knife, and secondly the re- disinfection of the surgeon's hands. The latter pro- cedure may become unnecessary if gloves are worn by the surgeon while the skin is being incised. One possibility, however, remains — inoculation ol the subcutaneous strata with the knife. This danger can not be obviated entirely, but it can be reduced to a minimum by slowly and carefully incising the integu- ments alone as far as possible. Now, as to the exposed skin-bacteria which can not 58 FRACTURES IN GENERAL. be destroyed or removed : how easy is it to set them hors de combat by simple protection! Sterile napkins are fastened to the subcutaneous tissues with miniature forceps, such as devised by the author, so that the skin margins are so well covered by them that they do not come into view during all the subsequent manipula- tions, which are done then on an absolutely sterile field. After the operation is completed the margins should be united by the subcutaneous method. If there is an absolute necessity for relaxation sutures, they should be applied through the skin, but about three-quarters of an inch distant from the wound margin, so that there is no direct contact with the wound-line. For such sutures, however, iodoform silk should be chosen. The same principle of protection should, under proper modifications, be employed in the opening of deep- seated abscesses. This principle was emphasized by the author before, in connection with the operation for pyothorax, in a paper read before the German Medical Society of New York in 1887. Then the author had tried to protect the fresh wound margins with iodoform- ether or collodion, before he had opened the pleural cavity, in order to prevent infection from the outflow- ing pus. Very little attention is paid to this point, as is evident from the custom of incising abcesses like ap- pendicial pus accumulations, intraosseous pus foci, etc. Once in a while the so-called disposition to infection is also spoken of. There is something in the theory, but only in a modified way. What favorable condi- tions are, for instance, offered by the skin of a work- ing-man ? And still, under the most aggravating cir- cumstances, infection is but seldom found among this TREATMENT. 59 class in general, while among the so-called better classes the most virulent forms of infection are ob- served, sometimes after a slight abrasion of the skin. This undeniable fact can not be explained simply by the difference of bacterial species or the degree of virulence. The explanation must be founded on bio- logic grounds. It seems that the plebeian cell in the strongly developed fist of a laborer resists, by virtue of its greater vitality, the fiercest enemy of mankind more energetically than the aristocratic one in the little-exercised hand of a man of leisure. On the other hand, there are a few members of the laboring- class who show a most striking tendency for virulent infections — a fact which can be explained by the peculiar action of chemic influences. It certainly makes some difference whether bacteria are introduced into the cell in a pure state or whether they are sus- pended in a greasy vehicle. The cell that is able to defend itself against the naked bacterium, so to say, may be powerless against one suspended in dirty machine oil. The principles of sterilization of the surgeon's hands are practically the same as those governing steriliza- tion of the skin of the patient. The only essential difference is, that the surgeon's hands do not need to be incised, wherefore the deep bacteria of the skin of his hand are not exposed, provided that there are no forcible efforts made to dislodge them and squeeze them out, so to speak. This would, indeed, be pro- voked only by brutal manipulations on the part of the surgeon. The author has repeatedly seen surgeons who had taken scrupulous care in their aseptic preparations 60 FRACTURES IN GENERAL. handle the intestine in the roughest manner, permitting it to come into contact with the abdominal skin and its wound margins, while manipulating the intestine after it had been taken from the abdomen for inspection. It speaks highly for the natural powers of defense of the human body, that in spite of such manipulations infection does not take place in every such instance. The same modus operandi holds good for the ster- ilization of the surgeon's hands, minus the prelimi- nary preparations. The length of time necessary for the scrubbing of the surgeon's hands may vary accord- ing to whether the surgeon had come in contact with septic cases shortly before sterilization or whether he was positive that he had remained clean for at least the last twenty-four hours. Furthermore, the most particular care must be given to the subungual space. Wicked tongues remark of certain physicians that they carry graveyards under- neath their finger-nails. To clean the subungual space a Braatz's nail-cleaner is advisable. The nails must be cut short and even with scissors, not trimmed with a file. The space is then scrubbed — first with the rough soap, and then with the alcohol water. It hardly needs mentioning that the surgeon should wash himself frequently, like other decent people, whether he perform an operation just at the time or not. In order to protect himself as much as possible he should wear rubber eloves when coming in contact with notorious bacterial shelters, such as the rectum, or when examining septic cases. He should also wash with especial care after an operation. However, to reduce the possibility of infection com- municated from deep-skin bacteria, gloves are advis- TREATMENT. 6 1 able. Their use was highly recommended by the author as early as in March, 1895, in his manual on "The Theory and Technique of Surgical Asepsis " (Saunders, Phila- delphia), page 94. It is true that the gloves some- times interfere with the technic of a delicate operation ; sometimes, however, they permit of easier handling — as, for instance, in intestinal work. Cotton gloves offer no insurance against the action of bacteria, but they act as a kind of filter bag, or as a bacteria trap, in which bacteria are not killed but arrested. When gloves are not worn, it must be remembered that the hands of the surgeon should come into contact with the wounded area as little as possible. Most manipula- tions can and must be done with instruments, which are always indisputably sterile after being boiled. So, for instance, a needle-holder should be used while sew- ing, instead of taking- the needle in the hand ; thumb- forceps should be used for holding tissues, instead of securing diem with the fingers. Erratic bacteria which are not pressed into the wound may perish, while in the midst of heaps of crushed cells they may develop in number and viru- lence. Thus may be explained why some surgeons who perform the dreaded operation of wiring patellar fracture without touching the wound surfaces with any- thing but instruments show splendid results, while the experience of others has been so sad that they have given up the operation on account of the "exception- ally great danger of infection." These considerations bring us near another most delicate question — namely, the surgeon's manual dex- terity. Since the advent of the aseptic era it seems to be supposed by many that this has become an unneces- 62 FRACTURES IN GENERAL. sary accomplishment. Under the auspices of asepsis countless technical sins are committed with a light ani- mus. Some are under the impression, for instance, that if they only stick to the letter of aseptic rules they do not need to care for a minute approximation — as, for instance, of the gut after resection. But in the event of the slightest diastasis the most thorough aseptic precautions prove to be valueless in such a case ; and, on the other hand, the invasion of a few- bacteria might have done little harm if the approxima- tion was done with great technical skill. How else could the miraculous results of some surgeons of the preantiseptic times be explained? The author need refer only to his distinguished teacher, Bernhard von Langenbeck, the results of whose plastic operations astonished the world. And his classic rules for plastic operations were outlined long before the days of antisepsis. Whoever saw von Langenbeck operate must have had the impression that he was an aristocrat in the best sense of the word. He had a most pronounced sense for natural cleanliness. It was not customary at his clinic to wear sterile gowns before the introduction of antiseptic rules, but the students wondered why the master, while operating, always wore a long, peculiarly made Prince Albert coat, which fitted high over the neck. This coat was always cleaned very thoroughly, sometimes to the disappointment of the operating nurse. There was a great contrast to the nonesthetic customs at other clinics of the same period. The hands were frequently washed, and the instruments, sponges, and the ligature material were kept extremely clean. Von Langenbeck's technic was that of an artist. TREATMENT. 63 His work was as delicate as a watchmaker's. His anatomic knowledge enabled him to make his skin in- cision in conformity with the deep seat of the lesion which indicated the operation. Naturally, he could also carry out his steps rapidly. Thus, by the short duration of his operation he exposed his patient to a smaller risk of infection. His gen tie handling of the tissues in general, his aversion to blunt operating, his predilection for sharp and clean instruments, were all points which counterbalanced to a certain degree the preantiseptic shortcomings. Such accomplishments should by no means be regarded as unimportant in this modern era. The surgeon should strive zealously to come as near to such perfection as possible. Thus we can see that the success of aseptic surgery does not depend upon a few principles, but that it is the happy combination of scientific knowledge, con- science, and manual skill which makes the surgical master, who must thoroughly understand and regulate the thousandfold different wheels of that wonderful organic clockwork — man. If we translate our considerations now into practice, the following maxims will result : 1. The superficial surface of the skin of the patient and of the surgeon's hands is sterilized after the princi- ples set forth above. The atmosphere being innocuous, all inorganic material being made aseptic by boiling, the skin surface being ascepticized, and the skin-glands that contain bacteria beino" hors de combat, it becomes evident that the only possible source of infection remaining would be rough manipulation on the part of the surgeon or of his assistants. 2. Aseptic gloves are worn by the operating surgeon 64 FRACTURES IN GENERAL. at least during the skin incision. The assistant who passes the instruments and the one who attends to the wound itself wear gloves throughout the whole opera- tion. 3. After incision the wound margins of the skin are covered with sterile napkins, which are fastened to the wound surface underneath the skin margins with mini- ature forceps, so that the skin wound is not touched at all during the subsequent manipulations. 4. The knife used for the skin incision must not be used for further incisions. The operation should be performed as rapidly as possible. 5. For uniting the wound margins of the skin the subcutaneous method should be preferred. 6. Forcible manipulations, especially blunt operating, should be avoided. Hemostasis must be very thor- ough. 7. The surgeon and assistants wear sterilized suits or gowns. Their heads must be covered with sterilized caps, because in bending over the field of operation it often happens that the heads of the surgeon and his assistant come in contact, whereby infectious material might be introduced into the wound. 8. Long beards are entirely unsurgical. 9. If a surgeon should suffer from rhinitis, tonsillitis, etc., he should use the most minute local precautions, or would better omit operating until recovery. It is self-understood that a surgeon should regard it as a crime to operate as long as he suffers even from a slight furuncle on his hand. With the expenditure of a little more time and trouble the same principles can be carried through in private practice also. TREATMENT. 65 In case of shock hypodermic saline infusions should be made. Whether a compound fracture is a priori infected or not can hardly be proved. The state of a compound fracture may with some probability be regarded as aseptic if the person who sustained it and the wound- ing object were both clean, and if but little time had elapsed before it came under the observation of a sur- geon. Still, whether aseptic or not, the principles of prophylactic disinfection and the carrying-out of the disinfecting process remain the same, as previously described. (See p. 52.) If there should be but a small wound, the surfaces of which will agglutinate before infection is possible, union by first intention is often secured, provided the premises of secondary infection are removed by the prophylactic disinfection. The further course of such fractures does not differ from that of a simple subcu- taneous fracture. But if there is extensive injury to the soft tissues, splintering of bones, perforation into a joint, etc., a large incision should be made. An attempt should always be made to first locate the splinters by the Rontgen rays. The loose splinters must be extracted, while those that still maintain an attachment to the periosteum should be left. Fragments of fat, muscu- lar shreds, fascia or crushed skin, and other debris should also be removed. Projecting points of bone should be trimmed off with bone-forceps. If the bone- fragments show much tendency to displacement, they should be wired or nailed together. (See technic of wiring, p. 69.) All hemorrhage must be carefully arrested ; foreign 5 66 FRACTURES IN GENERAL. bodies — such as splinters of wood, glass, and bullets — are to be extracted. Pockets underneath the integu- ment are split wide open. These manipulations should be performed only while irrigation with a o. i per cent, sublimate solution is maintained. If neces- sary, counteropenings are to be made, so as to permit the introduction of thorough drainage. Great care must be taken that the drains do not come between the bone-fragments. It is inadvisable to apply sutures to wounds of this kind. After small rubber drains, sur- rounded by iodoform gauze, are introduced into the counteropenings, the wound cavity, especially the pockets, is extensively packed with iodoform gauze. The wound is further protected with a large amount of some sterile and absorbent material. The most de- sirable substance for this purpose is moss-board, made of common German moss, the absorbent power of which is five times as great as that of gauze. It rep- resents a very soft and adaptable material, and it can be very easily sterilized. It is used best by being compressed into a tablet-like shape. (Fig. 23.) It can also be used loose, after being put into gauze bags, but it then loses its most convenient property — its immo- bilization power. The moss-board, after being dipped into cold water, adapts itself to the contours of the body like a plaster-of-Paris splint, over which it pos- sesses the great advantages of being absorbent and much lighter. (Fig. 23.) The bulky species of moss- board makes an ideal splint ; for, should the wound dis- charge exceed the absorbent power of the gauze directly over the wound, it takes up the superfluous discharge without impairing the usefulness of the moss as an immobilizing factor. To make a moss splint adaptable TREATMENT. 67 it must be dipped into, and not soaked in, cold water. If warm water is taken, the moss will swell up rapidly and the immobilization power is lost. If the secretion becomes abundant, the center of the moss-board, by absorbing it, swells up naturally, but there is so large a portion of the molded moss splint left that its value as an immobilizing apparatus does not become im- paired, any more than does a plaster-of-Paris dressing by the cutting of a fenestra. Immobilization will be so much the more reliable if a large wire splint is adapted besides.* (Fig. 12.) In case there is an indication for antiseptic lotions the wire splint does not conflict with their applica- tion. If this splint, after being boiled and loosely Fig. 12. — Simple wire splint. covered with sterilized gauze, is adjusted by a gauze bandage, it represents an absolutely sterile and per- meable material. Putrid cavities are packed with some antiseptic gauze (iodoform gauze) ; besides, a strong antiseptic drug should exercise a continuous influence. This will be accomplished if a strong bichlorid solu- tion is poured on the gauze dressing, which is thus kept permanently moist, the bichlorid solution coming continuously into direct contact with the wound sur- face. Accordingly, in well granulating wounds the dry treatment (iodoform gauze, moss splint, and over this the wire splint) should be preferred. But if there be a putrid cavity, the moist method (iodoform * See the author's " Manual on Asepsis," p. 200. 68 FRACTURES IN GENERAL. gauze packing and padded wire splint only) should be selected. For small wounds, provided there are good granulations, a fenestrated circular plaster-of- Paris dressing may be used and the wound may be treated through the fenestra. (Compare Fig. 5.) The same method may be selected when large wounds which have formerly had a putrid character have lost their virulence under the influence of a moist anti- septic dressing. Under this treatment many cases heal that formerly were destined to amputation. Still, there are cases in which the soft tissues are so extensively destroyed that conservative treatment may fail of success. In some cases there may be such extensive crushing and splin- tering that, from the very beginning, the preservation of the limb is out of the question, and amputation has to be resorted to. Such an extreme course fortunately represents at present but a small percentage of cases. Nowadays the surgeon should amputate only after hav- ing considered all the pros and cons most carefully. During the treatment of a compound fracture the patient has to be observed thoroughly. Great stress must be laid on taking the morning and evening temperature regularly. As far as the change of the dressings in compound fractures is concerned, the tendency at present is to disturb them as rarely as possible. The main indica- tions for change of dressing are : 1. When stitches or drainage-tubes require removal. 2. When secondary hemorrhage occurs. 3. When the discharge becomes so abundant that it can not be absorbed by the dressings, and a conse- quent transudation to the surface takes place. TREATMENT. 69 4. When the dressing has been so disturbed or moved that either the protection of the wound be- comes imperfect or there is risk of contamination by urine, feces, etc. '5. When the patient complains of intense pain. 6. When fever sets in and general symptoms point toward infection. 7. When there is any doubt as to the character of the fever. In case of non-union the fragments must be sutured together with silver wire (Fig. 13 a) or very stout cat- gut. To accomplish this, holes are bored near the ends of the fragments with a strong drill. Through these holes the suture material is drawn, and the fragments are then pulled together. Greater security of adapta- tion is obtained by resecting the bone-ends in a stair- case-like shape. (Fig. 13 b.) Good approximation may also be obtained by using long, four-cornered, well-polished nails, with which the fragments are nailed together. The nails must pro- ject to the extent of nearly an inch beyond the level of the integument. Steel is the best material for nails, and should be preferred to ivory ; not only because steel nails can easily be rendered sterile by boiling, but be- cause they can be extracted much more easily, while the ivory pegs become so decalcified after a little while by the carbonic acid in the tissues that they become rough and their extraction is thereby made difficult. Instead of nailing the fragments together, insertion of an ivory peg into the medullary cavity of the frag- ments may be employed. Implantation is another ingenious method. It con- sists in pointing the thinnest of the two fragments, so 7o FRACTURES IN GENERAL. that it can be inserted into the medullary cavity of the other and larger fragment. (Fig. 13 c.) Simple fractures may exceptionally be converted into compound fractures on account of great muscular spasm, from necrosis of a small fragment, or from the different sources of infection. The writer has observed three cases of suppuration in simple fractures of the femur, the subjects of which were boys of four, five, Fig. 13. — a, Bone-suture ; b, staircase-shaped exsection ; c, implantation of bone-ends. and seven years. They all suffered from tubercular inflammation of the adjacent knee-joint, the suppura- tion settino- in between the second and third week after the accident. Free incision becomes imperative in such cases ; after which treatment will be the same as before advised. (See p. 65.) Treatment of Disturbances in the Process of Repair. — In discussing this subject we shall do best to follow up the instances given under the heading ^ A T TMnT-7 P Q f Arranged in Question and ^-^ Answer Form. 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If there is much tendency to displacement, the ends may be resected in the form of steps, in order to make them fit closer. (Fig. 13 d.) The insertion of a pointed bone-end into the medullary cavity of the other fragment may also be considered. (Fig. 13 c.) In light cases energetically rubbing the ends of the bones together daily sometimes sets up so much local reaction that callus formation is induced. The produc- tion of moderate venous hyperemia by the use of a rubber tourniquet is also recommended. The same procedure may be used in cases of late union. Gangrene has to be treated after the principles set forth on page 68. Aneurysm has to be treated after general surgical principles. Compression of a nerve may be relieved by exposing it freely ; a wide incision being necessary if the nerve should be surrounded by much callus proliferation, which latter should be chiseled away. After such in- terference perfect recovery has been observed in a number of cases. (Figs. 66, 67.) Embolism has to be treated after general medical principles, stimulation of the heart being the main fac- tor (digitalis, caffein). / 2 FRACTURES IN GENERAL. Ankylosis offers but poor chances for complete resti- tution. The bony variety (compare Fig. 118) requires osteotomy, combined with the exsection of a bone- wedge. In fibrous ankylosis repeated forcible motion and manual correction of the abnormal position under anesthesia sometimes yield fair results, provided much time has not elapsed since the injury was sustained. Massage treatment is also a potent factor. But the most good can be done by early prophylaxis. If a fracture is situated in the vicinity of a joint, so that ankylosis is to be feared, the latter will certainly be avoided, if massage and active and passive motion are employed as soon as the swelling has subsided. Delirium tremens must be treated mainly by prophy- lactic measures. Alcohol (wine, whisky) should be given in moderate quantities to such individuals as are accustomed to its use. A ligfht diet should be observed. Opium and chloral in large doses may be freely ad- ministered. Patients who give an alcoholic history should be induced to walk about as early as possible. (See p. 42.) Pneumonia is treated after general medical princi- ples. The main factor in this connection is also pro- phylaxis. Aged persons especially must walk about as soon as possible. If in bed, their positions must fre- quently be changed. In fractures of the lower extrem- ity, if walking in a plaster-of-Paris dressing (compare Fig. 6) should prove to be inopportune, extension should be employed when aged people are concerned. When patients of advanced years can not be allowed to walk it is best to let them sit up in bed as much as possible, in order to prevent circulatory stasis and its train of evil consequences. PECULIARITIES OF FRACTURES IX CHILDREN. 73 PECULIARITIES OF FRACTURES IN CHILDREN. Although fractures in children must practically be considered from the same standpoint as those in adults, they present some characteristic deviations, which deserve a special description. Among the more marked varieties of infantile frac- tures the intrauterine and congenital and the rickety and spontaneous types may be mentioned. Almost peculiar to infancy and childhood are separation of the epiphysis and the so-called " greenstick " fracture. (Fig. 90.) It may be added that the scapula, sternum, and pelvis are but seldom fractured in childhood, while the clavicle, humerus, radius, thigh, and leg are more frequently involved than in adults. Fractures of the finorers, ^ ne skull, and the maxillas are also much rarer in childhood. In intrauterine fractures (see Figs, i, 2, and 93) normal union takes place in a large number of cases. Sometimes there is no union at all, and often a greater or lesser degree of deformity is observed. Congenital fractures are of moderate frequency. For detailed description see Part II. True epiphyseal separation — that is to say, a real chondro-epiphyseal division (Fig. 50), where the epi- physeal cartilage is sharply severed from the osseous end of the diaphysis — occurs in infants only, and is extremely rare, while osteo epiphyseal separation (Fig. 49) is frequently observed between the ages of four- teen and seventeen. In these latter cases the fracture line is not limited to the epiphyseal cartilage, but extends to the diaphysis. Traumatic separation has a 74 FRACTURES IN GENERAL. marked predilection for the epiphyses of the upper and lower ends of the humerus, the lower end of the radius, and the lower ends of femur and tibia. The different epiphyses naturally show a tendency to separation at various times. The dates of ossifica- tion and union of the epiphyses of the humerus, radius, femur, and tibia are, according to Ouain : In the humerus the nucleus of the head appears in the second, of the capitellum in the third, of the inter- nal condyle in the fifth, of the trochlea in the eleventh, and of the external condyle in the fourteenth year (see Fig. 174), while union between the lower epiphysis and the diaphysis takes place between the sixteenth and eighteenth years, and between the upper epiphysis and the diaphysis in the twentieth year. The lower epiphysis of the humerus consists of four nuclei, which ossify and unite between the eighth and eighteenth years, a fact that is of great importance in the correct interpretation of skiagraphs. In theradius (see Fig. 87) the nucleus of the lower end appears at the end of the second year, while that of the head follows at the fifth. The upper epiphysis and the diaphysis unite between the seven- teenth and eighteenth years, and the lower epiphysis and diaphysis join in the twentieth year. The nucleus of the lower end of the femur (see Fig. 138) appears as early as at the ninth month, while that of the head shows at the end of the first year. The head unites with the diaphysis at the eighteenth or nineteenth year, and the lower epiphysis follows after the twentieth year. The upper epiphysis of the tibia (see Fig. 138) appears at the time of birth, while the lower one shows in the second year. The lower tibial epiphysis unites with the diaphysis between the eighteenth and the nineteenth THE AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY. Edited by George M. Gould, M.D. Vols, for J 896, '97, '98, and '99, handsome oc- tavo volumes of SAUNDERS' AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY 1200 pages. Cloth, $6.50 net; Half Morocco, $7.50 net. Year-Book for 1900 in two volumes, about 600 pages each. 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AMERICAN TEXT-BOOK OF DISEASES OF THE EYE, EAR, NOSE, AND THROAT An American Text -Book of DISEASES OF THE EYE, EAR, NOSE, AND TKROAT. Contributions from 60 prominent Ameri- can Specialists, Edited by G. E. de Schweinitz, A.M., M.D., Professor of Ophthalmology, Jefferson Medical College, Philadelphia; and B. Alex. Randall, A.M., M.D., Clinical Profes- sor of Diseases of the Ear, University of Pennsylvania. Imperial octavo. \ 251 pages, 766 illustrations, 59 in colors. Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. & J> Jt J, JUST ISSUED. The present work makes a special claim to favor based on an encyclopedic, authoritative, and practical treatment of the subjects. Each section of the book has been entrusted to an author es- pecially identified with the subject, who there- fore presents his case in the manner of an expert. Particular emphasis is laid on the most approved methods of treatment, so that the book shall be one to which the student and practitioner can refer for information in practical work. <£ <£ <£ Send post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. PECULIARITIES OF FRACTURES IN CHILDREN. 75 years, while the upper epiphysis unites with the di- aphysis in the twentieth or twenty-second year. The Ronteen ravs, however, enabled the writer to observe the well-marked cartilaginous condition of the lower tibial epiphysis and a distinct epiphyseal line in a healthy man of twenty-four years. In dwarfs the epi- physis may remain cartilaginous up to the fortieth year. The symptoms are the same as those of the cor- responding fractures in adults. A most unpleasant feature of epiphyseal separation is the tendency to premature ossification, which leaves a stunted limb. In rickets (an infantile disease so frequent in Europe, and, thanks to its prosperity, very rare in this coun- try) the bones are brittle, in spite of their containing an abundant proportion of animal matter; so they are therefore very liable to break in consequence of even a small degree of violence. The greatest tendency to such fracture is shown by the clavicle and femur. Fragility in scurvy and in infantile paralysis of long standing are also well known. From clinical observa- tion the writer has received the impression that the presence of tuberculosis of the knee-joint also predis- poses to fragility of the femur in childhood. It is but natural that the subjective symptoms of frac- ture in a child should differ somewhat from those of analogous injuries in adults. Particularly the inability to call attention to pain and to the site of fracture must be considered in very young children. The author has, for instance, observed cases of infantile supramalleolar fracture where objective symptoms, especially displace- ment and deformity, were absent, while the subjective symptoms present pointed toward an injury of the hip- joint — a mistake which was cleared up only after dis- 76 FRACTURES IN GENERAL. coloration of the supramalleolar integument called attention to it. It must also be borne in mind that in children the pain of a fracture is less intense than in adults, and that in many cases it is even insignificant. (See p. 8 1.) If non-ossified tissues, such as the area of an epiphysis, are concerned, or if, as often happens in childhood, the periosteum has remained intact, other valuable signs — displacement, deformity, and crepitus — will naturally be absent. In fact, the line of fracture in some cases is so indistinct that it is difficult to fix it, even on a plate made by the Rontgen rays. (See Fig. I37-) The deformity caused by a greenstick fracture is often so slight that it may easily escape notice. These unpleasant features of infantile frac- tures are somewhat atoned for by their agreeable property of tending in most cases to rapid and almost certain union, a property which is due to the active formative process in the infantile bone and to the abundance of the callus production. These facts ex- plain the rare occurrence of deformities as well as of non-union in childhood. Non-union occasionally occurs in fractures sustained in liter or shortly after birth, and especially in cases of necrosis of the humerus and the tibia. (See Figs. 134, 135.) There is a decided influence upon the trophic nerves in this disturbance, probably due to a subtle derangement of the anterior horn of the spinal cord, in consequence of which the nutrition of the bone is inhibited. Consequently the bone is rendered weak and friable and its repair is hindered. The principles of treatment are identical with those applying for adults. Epiphyseal separation must also be treated according to the same rules. In children PECULIARITIES OF FRACTURES IN CHILDREN. J J the plaster-of-Paris dressing can be used to a much greater extent than in adults. (See p. 34, on treat- ment.) As to detailed rules, see Part II, on Fractures of Special Regions. PART II. FRACTURES OF SPECIAL REGIONS, FRACTURES OF THE SHOULDER AND UPPER EXTREMITY. CLAVICLE. Fracture of the clavicle comprises sixteen per cent, of all fractures. It is caused either by direct vio- lence — such as blows and falls — or by transmission of the impulse of a fall upon the shoulder or the extended arm. The longitudinal axis of this bone, which is interposed between scapula and sternum like a buttress, becomes compressed to a certain extent, and must break at the point of its least resistance. This is generally located between its medial and exter- nal thirds, the bone beine least in diameter there. 7 O (Fig. 14.) Fractures of the sternal and acromial ends are rather uncommon. While rare in the aged, fracture of the clavicle is extremely frequent in childhood. The character of the fracture is generally simple. In children infrac- tions are also frequently met with. Sometimes in chil- dren the sternal extremity is torn off. Symptoms. — The symptoms of fracture of the 78 THE PATHOLOGY AND TREAT- MENT OF SEXUAL IMPOTENCE. By Victor G. Vecki, M. D. From the second German edi- tion, revised and re- VECKTS SEXUAL IMPOTENCE written. Handsome Demi-Octavo vol- ume of nearly 300 pages. Cloth, $2.00 net. JUST ISSUED. Although no one denies that the sexual function is of the very greatest consequence to the indi- vidual as well as to society in general, yet the subject of impotence has but seldom been treated in this country in the truly scientific spirit that its pre-eminent importance deserves, and this volume will come to many as a revelation of the possibilities of therapeutics in this important field. The author ventures to assert that in "It is a well-written, scientific work . . . carl be recommended as a scholarly treatise on its subject, and it can be read with advantage by many practi- tioners."— Journal of the American Medical Asso- ciation. many cases it is a better deed to restore to an impotent man the power so precious to every individual, than to preserve a dangerously sick person from death, for in many cases death is preferable to impotence. This edition, although based on the German edition, has been entirely rewritten by the author in English. <£> <£ <£ For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. PRACTICAL POINTS IN NURS- ING* For Nurses in Private Practice. By Emily A. M. Stoney, Graduate of the Training - School STONEVS NURSING for Nurses, Lawrence, Mass*; Late Superintendent of the Training-School for Nurses, Carney Hospital, South Boston, Mass. 456 pages, handsomely illustrated. Cloth, $1.75 net. J> J- SECOND EDITION, REVISED. The author explains, in popular language, the entire range of private nursing as distinguished from hospital nursing, and the nurse is instructed how to meet the various emergencies that arise. A valuable feature of the -work will be found in the directions for improvising everything ordi- " There are few books intended for non-profes- sional readers which can be so cordially endorsed by a medical journal as can this one." — Thera- peutic Gazette. " A work that the physician can place in the hands of his private nurses with the assurance of benefit." — Ohio Medical Journal. narily needed in the sick-room. The Appendix contains much information of great value to the nurse, including Rules for Feeding the Sick; Recipes for Invalid Foods and Beverages ; Dose- list ; and a complete Glossary of Medical Terms a.nd Nursing Treatment. & & *£ v* %S* *£* For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. SHOULDER AND UPPER EXTREMITY. 79 Fig. 14. — Fracture of tbe left clavicle. Fig- 15- — Fracture of the clavicle. Slight axial displacement (after Hoffa). So FRACTURES OF SPECIAL REGIONS. clavicle are typical. The sternal end of the clavicle is elevated by the action of the sterno-cleido-mastoid muscle, while the acromial portion is pulled down by the weight of the arm and scapula. Thus, either simply an angle (Figs. 15 and 16) is formed, or the sternal end is overlapped by the acromial, the displacement so elevat- ing the fragment that the deformity becomes rather conspicuous even from simple inspection. The clavicle having ceased to be the buttress between shoulder and Fig. 16. — Fracture of the clavicle. Union after four weeks (axial displacement not reduced). thorax, the shoulder sinks downward and inward. The motions of the arm, especially elevation and abduction, naturally become painful, a symptom that finds its illus- trative expression by the patient generally supporting his elbow with the hand of the uninjured extremity. Instinctively the patient turns his hand toward the affected side in order to relax the sterno-cleido-mastoid muscle. Diagnosis. — A simple fracture of the clavicle is easily recognized. Inspection reveals displacement, SHOULDER AND UPPER EXTREMITY. 51 which is sometimes considerable. The writer has observed cases in which the two fragments were each directed upward, like two vertical posts, so that the tissues were forcibly pressed upward. Thus a picture, not unlike that of a tumor of the neck was created. (Fig. 17.) More or less dyspnea, which, of course, disappears as soon as reposition is effected, is also Fig. 17. — Fracture of the clavicle, showing considerable displacement, the upper fragment riding and lifting the integument forcibly upward, in a man thirty years of age (one week after the injury). present in these cases. It there is a clear history, fracture of the clavicle is seldom overlooked; but practical experience shows that it often happens that infants are dropped by careless nurses or mothers, and that the crying of the patients is attributed to some entirely different cause. To hide the careless- ness, a misleading report is sometimes given. Cases of fracture of the infantile clavicle are not rare in 6 82 FRACTURES OF SPECIAL REGIONS. which nothing- but an inability to lift the arm is noticed, and an ointment for the forearm is pre- scribed. Nothing shows the necessity of making it a principle always to denude the whole body in children, whenever there is the slightest suspicion of an injury Fig. 1 8. — Deformity caused by considerable displacement in a boy of ten years. to any bone, more especially since this oversight may lead to most unpleasant consequences to the attendant physician. The swelling on the point of fracture, the near ap- proach of the injured shoulder to the sternum, and the characteristic interruption in the bone line, common here as in all fractures, are all features that can easily be palpated, and are all unmistakable symptoms. Displacement is naturally absent in simple infraction, SHOULDER AND UPPER EXTREMITY. 83 and sometimes also in real fracture. In these rare cases it is the local pain in the first place that claims attention. It is obvious that, the signs of displacement lacking-, such conditions are often overlooked. A mis- take of this kind fortunately does not amount to much practically, since such cases are almost sure to heal without any treatment. (Fig. 16.) Whenever doubt exists, the Rontgen rays will furnish elucidation. Course. — Union is generally perfect in three weeks. Fig. 19. — Deformity caused by considerable displacement in the case illustrated by figure 18. Skiagram taken six weeks after the injury. Even in cases of extensive displacement, where reduc- tion is entirely neglected, union is to be expected. It is astonishing, that even where the overlapping of the fraoqnents causes considerable shortening of the clavicle, the function of the shoulder or the arm is but seldom impaired. (See Figs. 18 and 19.) From a cosmetic point of view such outcome will certainly be condemned. The disfigurement caused by the protrusion of the skin on account of the over- 8 4 FRACTURES OF SPECIAL REGIONS. lapping fragment is sometimes great, and if it concerns a female patient, the deformity will be liable to cause no little unhappiness. (Figs. 20 and 21.) It is remark- able, however, that sometimes there is hardly any pro- trusion, in spite of the riding of the very much dis- placed fragments. If there be such callus prolifera- Fig. 20. — Typical fracture of the clavicle in a girl of eight years. Marked deformity, caused by riding of upper fragment. tion, pressure maybe conveyed to the brachial plexus. Pseudarthrosis is extremely rare in fractures of the clavicle. Treatment. — As in all other fractures, prompt re- position is the main indication. This is generally done without any difficulty. It is made best while an assis- tant stands behind the patient, who sits in a chair. The SHOULDER AND UPPER EXTREMITY. 85 attendant pulls the injured shoulder backward. If reposition is imperfect, more force may have to be ap- plied by the assistant pressing his knee against the back of the patient while reposition is tried. Thus reposition is easy ; but keeping- the fragments well immobilized is a much more difficult matter. Many kinds of appliances have been devised for this purpose, most of them being intended to raise the shoulder and to bring it back and outward, so as to counteract the Fig. 21. — Fracture of the clavicle showing riding of the fragments. Same case as figure 20. Skiagram taken two days after the injury. displacing causes. These demands are well fulfilled by Velpeaii s dressing, which is applied best by means of a long roller bandage. After a small pad is put into the axilla of the injured side, the arm is conducted over the anterior thoracic wall and the hand is placed upon the uninjured shoulder. It is evident that this elevation of the hand pushes the injured shoulder as far upward as possible, while the adductor of the arm pulls the acromial end outward. The bandage is car- ried obliquely from the sound axilla over the injured 86 FRACTURES OF SPECIAL REGIONS. shoulder down to die elbow, whence it runs up to the axilla again, and so forth. Sayre s dressing (Fig. 22) is also much in favor. It demands three long, wide, adhesive plaster strips, the first one of them bein^ attached to the inner surface of the upper arm of the injured side and passing around the anterior surface of the arm backward over the back to the chest wall. (Fig. 22 a.) This procedure, which rotates the upper arm outward, prevents the clavicle from riding upward and pushes the elbow portion of Fig. 22. — Sayre's dressing: a, First strip ; />, second strip, front and back views. the humerus (and thus the shoulder also) backward, upward, and outward by pressing the elbow forward, downward, and inward. The second strip fortifies the position of the first by fastening the arm and hand of the injured side to the chest wall. (Fig. 22 b.) The strip starts from the uninjured shoulder, and, passing over the antibrachium and elbow to the dorsum, re- turns to the starting-point on the shoulder again. Now the fragments must be accurately adjusted and the deformity will necessarily disappear. The third strip, therefore, serves as a kind of a mitella only. It SHOULDER AND UPPER EXTREMITY. 87 surrounds the carpus of the injured side, and runs to the back after having- passed over the fractured area. It, however, elevates the hand somewhat and presses slightly upon the fragments. The Sayre dressing, while most ingenious, does not afford so firm a support as the Velpeau bandage or the author's. Furthermore, it has the great disad- vantage that the adhesive plaster often creates such a dermatitis that in summer time it can not be tolerated. The results obtained by the author's dressing were just as good, without expos- ing the patients to any dis- comfort. Absolute firmness is warranted by employing a moss splint that immobi- lizes the shoulder as well as the elbow. (Fig. 23.) The first step consists in drawing- the shoulders backward, while pressing the thorax (Fig. 24 a) or the knee against the patient's scapula. Then a moss splint, suitably trimmed for proper adaptation (Fig. 23), is applied to the shoulder. (Fig. 24 b.) The elbow portion is molded and folded in the same man- ner. If slightly dipped into lukewarm water, it will adapt itself well to the contour of the shoulder. The axilla is filled out with a pad of borated gauze. The hand also rests on a thick layer of borated gauze at the anterior thoracic wall, the fingers reaching up to the sound clavicle. Fig. 23. — Moss splint, trimmed for author's dressing. (See Fig. 24 b.) A TEXT-BOOK OF EMBRYOL- OGY. By John C Heisler, M.D., Professor of Anat- omy in the Medico- Chirurgical College, HEISLER'S EMBRYOLOGY Philadelphia. Octavo volume of 405 pages, with 190 illustrations, 26 in colors. Cloth, $2.50 net. JUST ISSUED. The facts of embryology having acquired in recent years such great interest in connection with the teaching and with the proper compre- hension of human anatomy, it is of first im- portance to the student of medicine that a con- cise and yet sufficiently full text-book upon the subject be available. It was with the aim of presenting such a book that this volume was " The book is written to fill a want which has dis- tinctly existed and which it definitely meets; com- mendation greater than this it is not possible to give to anything." — Medical News, New York. written, the author, in his experience as a teacher of anatomy, having been impressed with the fact that students were seriously handi- capped in their study of the subject of embry- ology by the lack of a text-book full enough to be intelligible, and yet without that minuteness of detail which characterizes the larger treatises, and which so often serves only to confuse and discourage the beginner. <£ jit Jt Jt jt For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. A MANUAL OF DISEASES OF THE EYE. By Edward Jackson, A.M., M.D., for- merly Professor of Diseases of the Eye in the Philadelphia JACKSON ON DISEASES OF THE EYE Polyclinic and College for Graduates in Medicine. J2mo, 604 pages, with J 78 illustrations from drawings by the author. Cloth, $2.50 net. JUST ISSUED. This book is intended to meet the needs of the general practitioner of medicine and the begin- ner in ophthalmology. More attention is given to the conditions that most be met and dealt with early in ophthalmic practice than to the rarer diseases and more difficult operations that may come later. <£ <£ *J* S <£ <£ S It is designed to furnish efficient aid in the actual work of dealing with disease, and there- fore gives the place of first importance to the recognition and management of the conditions present in actual clinical work. For practitioners in other departments of medicine and surgery, the most important phase of ophthalmology is that of the relations of ocular symptoms and lesions to general diseases. A special chapter is devoted to these relations, and the references it contains will put the reader in touch with the related facts in all the preceding chapters. J* J* For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. SHOULDER AND UPPER EXTREMITY. 89 Now the sunken arm is elevated by passing- a roller bandage under the elbow, over the clavicular area of the healthy side. Then the lower third of the humerus is tightly drawn to the thorax and transversely fixed by a turn of the bandage. Finally, the elbow is sup- ported by another turn passing over the injured area. (Fig - . 24 c.) In children this dressing should be pro- tected by broad strips of rubber adhesive plaster. The author's dressing can be used in all the different types of clavicular fracture, but has proved to be espe- cially useful when simultaneous injuries of the integu- ment exist. (Compare p. 66 on moss dressings.) SCAPULA. Fractures of the scapula are rare, comprising only about one per cent, of all fractures. They concern either its spine, body (Fig. 25), neck (Fig. 26), the acromion (also Fig. 25), or the coracoid pi'ocess. Fractures of the spine and the body of the scapula are either simple fissures or fractures without any displacement, and consequently heal under almost any treatment. The principal signs are ecchymosis, crepitus, and pain. A correct diagnosis is often only possible with the aid of the Rontgen rays. The treatment consists in immobilizing the arm with a splint, which surrounds the shoulder and passes over the scapula to the spine. Fracture of the neck of the scapula (Fig. 26) in itself is extremely rare. It occurs more frequently in connection with a fracture of the floor of the glenoid cavity. The severed glenoid cavity sinking downward and inward, the shoulder loses its convex shape and the arm appears longer, so that this injury 9° FRACTURES OF SPECIAL REGIONS. is very liable to be confounded with the subcoracoid dislocation of the humerus. (Figs. 34, 35, 36.) But in this fracture the arm is freely movable in all directions, while in dislocation free motion is arrested. Further- more, the convexity of the shoulder at once springs up again as soon as the humerus is pushed upward and outward, while in the case of dislocation the nor- Fig. 25. — Stellate splinter fracture of the scapula. mal contour of the shoulder appears only when the reduction has been made perfect. The treatment consists in Velpeau's or the author's dressing. (See p. 87.) Union is generally complete in four weeks. Fracture of the acromion (compare Fig. 25) is nearly always caused by direct violence (fall or blow). The signs — generally well marked — are ecchymosis, SHOULDER AND UPPER EXTREMITY. 91 pain, crepitus, flattening, and sinking downward and inward. Even if there be extensive blood extrava- sation, the sharply localized pain and the crepitus, Fig. 26. — Fracture of the neck of the scapula (after Hoffa). which is never absent, are symptoms too characteris- tic to permit of a mistake. The treatment is practically the same as that of frac- ture of the neck of the scapula. (See p. 90.) Union is generally perfect in about three weeks. Even it 92 FRACTURES OF SPECIAL REGIONS. there be fibrous union only, there is no functional dis- turbance. Fracture of the coracoid process is rare and is also generally caused by direct violence. After this fracture the short head of the biceps muscle and the coracobrachialis and the pectoralis minor muscles pull the coracoid process inward and downward. The dis- placement is hardly noticeable, but the localized pain, the mobility of the fragment, and the disturbance of the function of the arm are marked symptoms. The treatment is the same as that of the fracture of the neck of the scapula. HUMERUS. Fractures of the humerus comprise about eight per cent, of all fractures. They are best classified according to their seat, as fractures of the upper end, of the diaphysis, and of the lower end. All the dif- ferent varieties of fracture of the humerus also occur in children. Fractures of the upper end of the humerus are caused either by direct or indirect violence. They are subdivided as fractures of the anatomic and surgical necks, — including the traumatic epiphyseal solution of the upper end of the humerus, the so-called trans- tubercular fracture, — and fractures of the tuberculum majus and minus. I. Fracture of the anatomic neck of the humerus (Fio-. 27) is caused by direct violence, especially by a fall upon the outstretched hand. Like the intra- capsular fracture of the femur, it is an intra-articular fracture. It is especially observed in aged persons, A TEXT-BOOK OF OBSTETRICS. By Barton Cooke Hirst, M.D., Pro- fessor of Obstetrics in the University of Pennsylvania. HIRST'S OBSTETRICS Handsome octavo volume of 846 pages. 6\& illustrations and 7 colored plates. Cloth, $5.00 net; Half Mo- rocco, $6.00 net. J- J> J> J> J> SECOND EDITION. This work is intended as an ideal text-book for the student no less than an advanced treatise for the obstetrician and for general practitioners. It represents the very latest teaching in the practice of obstetrics by a man of extended experience and recognized authority. The book emphasizes especially, as a work on obstetrics should, the "The illustrations are numerous and are works of art, many of them appearing for the first time. The arrangement' of the subject-matter, the foot-notes, and index are beyond criticism. As a true model of what a modern text-book on obstetrics should be, we feel justified in affirming that Dr. Hirst's book is without a rival." — New York Medical Record. practical side of the subject, and to this end pre- sents an unusually large collection of illustra- tions. Most of these are new, and the collec- tion will form a complete atlas of obstetrical practice. This work records the wide experi- ence of the author, which fact, combined with the brilliant presentation of the subject, renders it one of the most notable bocks on obstetrics. For sale by all Booksellers, or sent post-paid on receipt of price, W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. LECTURES ON THE PRINCI- PLES OF SURGERY. By Charles B. Nancrede, M.D., LL.D., Professor of Surgery and NANCREDE'S PRINCIPLES OF SURGERY. of Clinical Sur- gery, University of Michigan, Ann Arbor; Emeritus Professor of General and Orthopedic Surgery, Phi- ladelphia Polyclinic. Octavo volume of about 350 pages, handsomely illus- trated with original drawings and pho- tographs. Cloth, $2.50 net. J- J> jt JUST ISSUED. Although many excellent works have been written treating of the Principles of Surgery, the attempt to render them too comprehensive has marred their usefulness for the undergrad- uate. The present book is based on the lectures delivered by Dr. Nancrede to his undergraduate classes, and is intended as a text-book for stu- dents and a practical help for teachers. By the careful elimination of unnecessary details of pathology, bacteriology, etc., which are amply provided for in other courses of study, space is gained for a more extended consideration of the Principles of Surgery in themselves, and of the application of these principles to methods of practice. Jt<£<£<2*<£<£jtjtjt For sale by all Booksellers, or sent post-paid on receipt of price. W". B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. SHOULDER AND UPPER EXTREMITY 93 which fact is well explained by the senile atrophy of the bone tissue. The signs are abnormal mobility, crepitus, loss of function, and pain. The extracapsular character nat- urally prevents palpation of the second fragment. If the tubercula, together with the diaphysis, are inwardly displaced, the shoulder becomes flattened so that a Fig. 27. — a, Exterior appearance ; b, fractured head, showing slight outward displacement (after Hoffa). deformity similar to that of the subcoracoid dislocation is created. (Compare Fig. 36.) But it should be re- membered that in fracture of the anatomic neck there is much more shortening of the arm than in disloca- tion, and that in dislocation free motion is arrested. Even in the case of impaction, mobility is much freer in the case of a fracture than it is in a dislocation. So far as the possibility of confounding this type 94 FRACTURES OF SPECIAL REGIONS. with the fracture of the scapular neck (Fig. 26) is concerned, in which the arm is also pushed toward the chest, it should be considered that in fracture of the neck of the humerus (Fig. 33) the arm is shortened, while in fracture of the neck of the scapula it is elongated. If impaction be present, union may become perfect ; if not, the severed fragment may undergo necrosis, since it would receive no blood-supply. Fortunately, this fracture type is not absolutely intracapsular in most cases ; that is to say, the fragment is not severed in its whole extent, but it still adheres by portions of the capsule, so that the vascular supply is not entirely cut off. Sometimes callus proliferation is so abundant that the function of the joint is inhibited. (Figs. 29 and 30.) The treatment consists best in the application of a well-padded collar splint, which extends from the neck over the shoulder and the extensor portion of the arm and antibrachium to the dorsum of the hand. Ex- tension by weight is also advised. But while this method of treatment is excellent as far as the final result is concerned, it has the disadvantage of confining the patient to bed. II. Fracture of the surgical neck of the humerus occurs much more frequently than fracture of the anatomic neck, and is generally caused by direct violence (fall on the shoulder) ; sometimes indirectly (fall on the hand or elbow). It has its analogue in the extracapsular fracture of the neck of the femur. It is common in all ages. (Figs. 31, 33.) Signs. — The line of fracture is found below the tuberosities. The arm is shortened more than in frac- DISEASES OF THE EYE. A Hand- book of Ophthalmic Practice. By G. E. de Schweinitz, De SCHWEINITZ ON DISEASES OF THE EYE M.D., Professor of Ophthalmol- °gYt Jefferson Medical College, Philadelphia; Pro- fessor of Diseases of the Eye in the Philadelphia Polyclinic Octavo. 696 pages, illustrated. Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net. THIRD EDITION, REVISED. The book has been thoroughly revised and much new matter introduced. Particular atten- tion has been given to the important relations " It is a very useful, satisfactory, and safe guide for the student and the practitioner, and one of the best works of this scope in the English lan- guage." — Annals of Ophthalmology. which micro-organisms bear to ocular disorders. A number of special paragraphs on new subjects " The book will recommend itself by its thor- oughly practical tone, its clearness and terseness of language, and its modernism." — New York Aledical Journal. have been introduced, and certain articles, in- cluding a portion of the chapter on Operations, have been largely rewritten. ^ ^ Jt ^ J* For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. A HANDBOOK FOR NURSES. By J. K. Watson, M.D., Edin., Assist- ant House=Surgeon, Sheffield Royal In- firmary and Shef- field Royal Hospi- WATSON'S HANDBOOK FOR NURSES tal; Late House-Surgeon, Essex and Colchester Hospital. Crown octavo, 413 pages, with 73 illustrations. Cloth, $1.50 net. J> £• J- J- & J- J> JUST ISSUED. This work aims to supply in one volume that information which so many nurses at the present time are trying to extract from various medical works, and to present that information in a suitable form. Nurses must necessarily acquire a certain amount of medical knowl- edge, and the author of this book has aimed judiciously to cater to this need with the object of directing the nurses' pursuit of medical infor- mation in proper and legitimate channels. Jt <£* The book represents an entirely new departure in nursing literature, insomuch as it contains useful information on medical and surgical matters hitherto only to be obtained from ex- pensive works -written expressly for medical men* <^* «*5* %?& &* t£* «£* %£* •£* <^* <^* For sale by all Booksellers, or sent post-paid on receipt of price. "w\ B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. SHOULDER AND UPPER EXTREMITY. 95 Fig. 28. — Fracture of the anatomic neck of the humerus, showing outward displacement of the head and impaction ; girl of nine years. (One week after the injury.) Fig. 29. — Fracture of the anatomic neck of the humerus, showing outward displacement of head and abundant callus proliferation in a man of sixty-four years (three weeks after the injury). H Li 1 ^H M | Fig- 3°- — Fracture of the anatomic neck of the humerus, showing abundant callus proliferation, inhibiting free motion. Fig. 31. — Fracture of the surgical neck of the humerus (after Hofla). 96 Fig. 32. — Ideal union in fracture of the surgical neck of the humerus, show- ing perfect apposition and normal callus formation, in a boy of eight years. (Two weeks after the injury.) Fie. -Fracture of surgical neck of left humerus. Oute snowing angular deformity below the fracture, and ecchymosis in front of the shoulder. 7 97 98 FRACTURES OF SPECIAL REGIONS. ture of the anatomic neck. The lower fragment is pushed inward, the pectoralis major and latissimus dorsi muscles pulling it toward the thorax ; and at the same time it is drawn upward by the biceps, triceps, and coracobrachialis muscles. There is also ecchy- mosis, abnormal mobility, displacement, and generally crepitus. As to displacement, it is found that the end of the diaphysis may be directed inward, in other cases outward ; the latter variety being by far the rarer one. In case of inward displacement (Fig. 33) tne arm is abducted and the axis of the arm is directed toward the clavicle or the coracoid process, while in outward displacement the arm is kept in adduction. If the fracture is impacted, it may be confounded with dislocation. In preglenoid (subcoracoid) disloca- tion (Figs. 34 and 35) the infraclavicular fossa, on account of the projection of the dislocated head of the humerus, appears as if it were filled up. If the surgeon only takes the trouble of palpating this pro- truding point, he will receive the impression of the presence of a hard body of globular shape, which follows all motions of the shaft of the humerus. Now, there is no other organ in this region that could be confounded with this projection represented by the dislocated head of the humerus. Indeed, the flattening of the shoulder, the axial change, and the flat promi- nence of the anterior aspect of the axillary region should be sufficient indications of the presence of a dis- location. And if there be a subglenoid (axillary) dis- location (Fig. 36), there must invariably be a diastasis between the head of the humerus and the acromion, which is of such considerable extent, sometimes, that the fingers can be introduced into the gap. The SHOULDER AND UPPER EXTREMITY. 99 surgeon should, therefore, always try to insert his hand between the acromion and the head of the humerus, because if he succeeds, he is almost sure to have a dislocation to deal with, while if he does not, he knows that the head of the humerus is at its proper place. This would indicate that if there be Fig. 34. — Preglenoid dislocation of the right humerus (front view). false motion, a fracture must be assumed. If the arm is now rotated, while the head is steadied, the latter will not move. Sometimes the rough edges of the fragments can be palpated, if the axillary portion is firmly grasped. As to further contradistinction from dislocation and from fracture of the anatomic IOO FRACTURES OF SPECIAL REGIONS. neck, compare page 93. In tumors of the shoulder (Fig. 37), in inflammatory (rheumatic) and tubercular processes, it happens sometimes that if a history of an injury is given, the swelling is erroneously taken for callus proliferation. Treatment. — Reposition is accomplished by pulling Fig. 35. — Preglenoicl dislocation of the right humerus (back view). the arm downward and outward, under anesthesia, if necessary. Immobilization is attained either by a collar splint (see p. 45) or by the application of a plaster-of-Paris dressing, which is supported by coap- tation splints around the fractured area and its imme- diate vicinity. An axillary pad should be employed SIKH I.DEK AND UPPER EXTREMITY. IOI and the forearm should be kept rectangularly ban- daged. If there be great tendency to displacement, as is especially found in oblique fractures of the surgical neck of the humerus, permanent extension, while the patient is confined to bed, should be preferred. In a week the patient can get up, after which extension is Fig. ^6. — Subglenoid dislocation. employed during the night only, the patient being per- mitted by day to walk around after a collar splint has been applied. (Fig. 8.) As shown by the skiagram (Fig. 32), excellent results can be obtained by this treatment. In this connection the traumatic epiphyseal separation 102 FRACTURES OF srECIAL REGIONS. of the upper end of the humerus must also be mentioned, a condition frequently observed in children before the process of ossification in the epiphyseal cartilage is complete. The signs are about the same as those of fracture of the surgical neck of the humerus, except that the Fig- 37- — Osteosarcoma developing after a fall upon the outstretched hand, and erroneously taken for callus proliferation. (See p. ioo. ) crepitus is less marked on account of the soft charac- ter of the friction between the fractured surfaces (car- tilaginous crepitus). The treatment is the same as in fracture of the sur- gical neck. It is sometimes impossible to keep the fragments in good position, or even to reduce them at all. When reposition is impossible, the fragments SHOULDER AND UPPER EXTREMITY. IO must be united by nailing or sewing them together. (See p. 69.) If reposition fails to be perfect in chil- dren, further growth of the bone is arrested. III. Transtubercular fracture (Fig. 38) is always the result of direct violence. The line of fracture is on a Fig. 3S. — Transtubercular fracture caused by direct violence, in a man of forty-five years (eight weeks after the injury), leaving considerable functional dis- turbance. level with the tubercula, and its direction is transverse. There is a marked depression below the acromion. Crepitus can always be produced by rotating the arm, provided there is no impaction. Displacement io4 FRACTURES OF SPECIAL REGIONS. is nearly always present. The nature of this injury generally not being recognized without the aid of the Rontgen rays, it is obvious that no effort is made to reduce the displaced portion. Consequently, there is Fig. 39. — Fracture of the diaphysis of the humerus, showing riding ot fragments, in a lad of fifteen years. (One day after the injury.) always more or less deformity and interference with free motion in the joint. The treatment consists in proper reposition under the control of the Rontgen rays, and the after-treat- ment is identical with that for fracture of the neck of the humerus. IV. Fracture of the tuberculum ma jus or minus is al- ways accompanied by a dislocation, and is character- An American Text-Book of GENITO- URINARY DISEASES, SYPHILIS, AND DISEASES OF THE SKIN. By 47 eminent Specialists. Edited by L. Bolton Bangs, M.D., Con- sulting Sur- geon to St. Luke's Hospi- AMERICAN TEXT-BOOK OF GENITO-URINARY DISEASES, SYPHILIS, AND DISEASES OF THE SKIN tal and the City Hospital, New York; Professor of Genito-Urinary Surgery, University and Bellevue Hospital Medical College, New York ; and W. A. Hardaway, A.M., M.D., Profes- sor of Diseases of the Skin and Syphi- lis in the Missouri Medical College, St. Louis. «3* J> J> J> J- <£• <£• JUST ISSUED. Complete in one imperial octavo vol- ume of J 229 pages. Illustrated with over 300 engravings and 20 full-page colored plates. Cloth, $7.00 net ; Sheep or Half Morocco, $8.00 net. J> J- J> Sent post-paid on receipt of price. "W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHILDREN. By 65 Eminent Contributors. Edited by Louis Starr, M.D., Consulting AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN Paediatrist to the Maternity Hospital, Philadelphia. Handsome Imperial Octavo Volume of \ 244 pages, pro- fusely illustrated. Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. J> SECOND EDITION, REVISED. To keep up with the rapid advances in the field of pediatrics, the whole subject-matter embraced in the first edition has been carefully revised, new articles added, some original papers amended, and a number entirely rewritten and brought up to date. The new articles include "Modified Milk and Percentage Milk-Mixtures/' "Lithe- mia," and a section on ** Orthopedics." Those rewritten are "Typhoid Fever," "Rubella," " Chicken-pox," " Tuberculous Meningitis," 44 Hydrocephalus," and ** Scurvy," while exten- sive revision has been made in " Infant Feed- ing," "Measles," " Diphtheria," and "Cretin- ism." The volume has thus been increased in size by a very considerable amount of fresh material. i^^i^»»^'^^"»*»"^'«'" Send post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. SHOULDER AND UPPER EXTREMITY. 105 ized by pain, functional disturbance, and diastasis of the fractured area. The treatment consists of relaxation of the muscles that are inserted at the tubercula by proper rotation, and of immobilization by a collar splint. Fracture of the diaphysis of the humerus is in the great majority of cases caused by direct vio- lence, and is of frequent occurrence. While in children (Fig. 39) the transverse direction is predominant, in adults the line of fracture is generally oblique. (Fig. 40.) As a rule, there is but little displacement in transverse fractures of the shaft, while in oblique frac- tures displacement is always present. It is then either longitudinal or axial. The signs are ecchymosis, pain, crepitus, abnormal mobility, and loss of function, besides displacement. In most cases union becomes perfect in from five to six weeks. The radial nerve may experience the same fate, since its situation directly on the periosteum favors its laceration in splintering fractures. The same nerve may also be injured by overabundant callus prolifer- ation, so that it becomes tightly embedded — in fact, in- carcerated — in the callus-tissue. (See Fig. 41.) The consequences of this condition are grave disturb- ances in the sensory as well as in the motor sphere. Protrusion of badly united fragments, conveying pres- sure upon the brachial artery or vein, produces exten- sive edema of the extremity. (Fig. 40.) Treatment. — If there is pronounced tendency to dis- placement, a collar splint (p. 45) will correct the trouble. Any other kind of splint that has a shoulder- cap would be useful, if properly applied. In applying 106 FRACTURES OF SPECIAL REGIONS. any kind of dressings great care should be taken to avoid pressure on the axilla. If there be marked Fig. 40. — Double fracture of the diaphysis of the humerus, in a man of fifty years (was rickety when a child), two months after the injury. Protruding lower fragment, causing extensive edema of arm and hand by pressure upon the brachial vessels. tendency to displacement, extension by a heavy weight, attached to an adhesive plaster dressing, should be made for at least two weeks. SHOULDER AND UPPER EXTREMITY. IO; In a case of pressure-paralysis of the radial nerve, caused by callus proliferation, neurolysis, as described on page 71, should be performed. In most of the cases where the incarceration of the nerve is relieved by chiseling off the callus-tis- sue the paralysis disappears promptly. Pseudar thro sis is much more frequently observed in fracture of the humerus than in that of any other bone, the diaphysis preeminently being concerned. According to Gurlt, thirty-four per cent, of pseudarthroses affect the humerus. This de- plorable condition is always due to the insufficient coapta- tion of the fragments, which generally permits the interven- tion of muscular tissue. Some- times true new joints, contain- ing cartilage and synovia, are formed, as described in pseud- arthrosis of the tibia. In cases of short standing stretching- the elbow and the application of a long extension splint, reaching from the hand to the shoulder, may be employed. Then, while the arm hangs down, permanent stretching of the fractured area is accomplished. In most cases, however, subperiosteal resection followed by bone- suture must be performed. Under the aegis of the Rontgen rays pseudarthrosis Fig. 41. — Abundant callus formation, induced by lateral displacement in fracture of the lower end of the humerus, and causing pressure on radial nerve. io8 FRACTURES OF SPECIAL REGIONS. of the humerus has become unpardonable, since under their guidance any slipping-out of the fragments can easily be noticed and corrected. Fractures of the lower end of the humerus are frequent and show different varieties, the cor- rect recognition of which is often extremely difficult, and without the aid of the Rontgen rays is some- times impossible. They are usually caused by direct violence. In children they are nearly invariably the re- sult of falls. Separation of the lower epiphysis in child- hood is sometimes con- founded with backward dis- location of the radius and ulna. The different varieties are best classified as supra- condylar, diacondylar (in- cluding epiphyseal separa- tion), epi 'condylar, and inter- condylar (including intra- articular separation of the capitulum humeri). I. Supracondylar fracture (Figs. 42 and 43) is transverse in the majority of cases, but sometimes its line is oblique. It principally occurs in children under twelve years of age — a period in which the locality of this fracture type is determined by the softness of the bone-tissue. This explains why in children a fracture nearly always results from a fall upon the hand or elbow, while the same accident gen- erally produces a dislocation in adults. In children this type is sometimes complicated by a vertical frac Fig. 42. — Exterior view of supra condylar fracture. SHOULDER AND UITER EXTREMITY. IO9 ture, which extends into the joint, so that the so- called T-fracture results. Supracondylar fracture has been erroneously described by some authors as epi- physeal separation. The signs of this fracture often resemble those of the backward dislocation of the antibrachium (see Figs. 44 and 45), there being three main signs corn- Fig. 43. — Oblique supracondylar fracture in a man of thirty-tive years (four days after the injury). mon to both injuries : namely, shortening, false posi- tion, and the axial direction. There is always a back- ward displacement, the lower fragment being pulled back by the triceps muscle. (Fig. 42, 43.) But in con- trast to dislocation, abnormal mobility and crepitus are always present in fracture. It must also be con- sidered that flexion at a rio-ht anode as well as exten- sion to the full limit is always possible in fracture. I 10 FRACTURES OF SPECIAL REGIONS. Another striking point of differentiation is the return of the deformity, whenever reposition has been made ; while in dislocation the deformity disappears as soon as reposition is done. A further pathognomonic sign is the absence of the projection of the radial head, which in a case of dislocation can always be easily palpated. The olecranon is always situated higher in dislocation than in fracture. In cases in which it Fig. 44. — Backward dislocation of the elbow (exterior view). is pushed backward together with the transverse epi- physeal line, it is found in the direction of that line. To give a resume, it should be considered that in dislocation the flexor side of the forearm and the extensor side of the upper arm appear shortened, the tendon of the triceps muscle appearing like a small arch, the concavity of which is directed toward the olecranon. This bone portion makes itself conspicuous then as a marked projection posteriorly. Thus, two SHOULDER AND UPPER EXTREMITY. I I I lateral grooves are formed. It will also be found that the trochlea can be palpated in front, while the out- lines of the joint-surface of the radial head can be easily grasped in the back. In dislocation the trans- verse diameter of the joint always remains normal. The diag7iosis of fracture is indisputable, as soon as the presence of false motion is established. This is done by grasping the lower fragment on its projec- Fig. 45. — Backward dislocation of the elbow. tions, the epicondyles, and pushing them to and fro. Crepitus is also never absent during these manipula- tions. In T-fractures the prognosis is particularly grave in view of the severe complications of the joint. The treatment consists in reducing the fragment by makine extension on the hand and antibrachium under anesthesia, if necessary. Whether immobilization is I I 2 FRACTURES OF SPECIAL REGIONS. better kept up in the extended or in the flexed posi- tion should be determined by the ease with which the fragments can be kept reduced in either of them. In most cases the decision of this much-discussed ques- tion should be left to the surgical instinct. There is no doubt that the rectangular position of the arm is by far the most agreeable for the patient ; but it should not be the consideration of the patient's com- fort that decides the position in so important an in- Fig. 46. — Supracondylar fracture, showing slight backward displacement, in a girl often years. (Two months after the injury.) jury, but that plan should be adopted that assures the securest and most perfect apposition. A circular plaster-of-Paris dressing, reaching from the shoulder to the wrist, is preferred by the author lor immobilization. In most cases the fragment is best reduced and retained while forcible traction is made on the hand by an assistant, the surgeon or another assistant pushing the fragment inward with the left thumb. During this manipulation the bandages are applied. If after a week's time the rectangular SHOULDER AND UPPER EXTREMITY. I 1 3 position is gently and gradually resumed, the ten- dency to displacement having been overcome, the question of comfort may be considered. More than in any other fracture type, frequent inspec- tion, control by the Rontgen rays, and eventual change of dressing" is indicated. After three weeks, active and passive motion, together with massage treatment, should begin. It is only when thorough control is practised throughout the treatment that the untoward outcome of varus or valgus formation is certainly pre- vented. Fig. 47. — Diacondylar fracture, causing considerable forward displacement, in a boy of twelve years (outer view). If the tendency to displacement can not be over- come, extension, in combination with a wire splint, should be used for two weeks. The radial as well as the median nerve may become lacerated by the splintering of the bone. Whenever these injuries are diagnosticated, which is always possi- ble under the auspices of the rays (compare Fig. 41), neurorrhaphy should be performed without delay. The cubital vessels may become lacerated in the same manner, in which case immediate ligation alone can prevent gangrene of the arm. II. Diacondylar fracture (fracture of the cubital pro- ii4 FRACTURES OF SPECIAL REGIONS. cess) (Figs. 47 and 48) is caused directly by a fall upon the elbow or indirectly by a fall upon the hand, and is rather rare. It always extends into the joint, and is, therefore, in fact, an intra-articular fracture. The line of fracture is transverse, as a rule, and runs along- side the cartilaginous joint-surface. The treatment must be conducted after the same principles as that of the supracondylar fracture, with Fig. 48. — Diacondylar fracture showing displaced fragment attached in oblique direction, thus causing a resemblance to backward dislocation of the forearm. Skiagram of figure 47, taken six weeks after the injury. the difference that motion and massage must begin as early as one week after the injury is sustained. Epiphyseal separation in children must be considered under the same view, and the treatment should be conducted after the same principles as the diacondylar fracture. They are of either the osseous (Fig. 49) or the cartilaginous (Fig. 50) type. SIloULDER AND UPPER EXTREMITY. I I 5 III. Epicondylar fracture is far more frequent than the former varieties. It is caused mainly by direct violence, and especially by a fall upon one or the other side of the elbow region. It is either oblique and extends into the joint {intra-articular epicondylar frac- ture), or extra- articular and concerns the epicondyle only {isolated epicondylar fracture). The intra-articular epicondylar fracture, or the epi- condylar fracture proper, concerns either the internal or the external epicondyle, and its line is always Fig. 49. — Osteo-epiphyseal separation of lower end of the humerus in a boy of five years, showing no displacement (one day after the injury). oblique. The internal epicondyle becomes fractured if the fall is sustained while the arm is abducted; but the external epicondyle is fractured while the arm is in adduction. In both instances the line of fracture reaches the joint. The fracture of the internal epicondyle (Fig. 5 1 ), which is caused by a fall upon the middle of the elbow, is rarer than the fracture of the external epicondyle. The signs are slight displacement, crepitus, abnor- mal mobility, and swelling above the internal epicon- u6 FRACTURES OF SPECIAL REGIONS. dylar region, the latter so marked that this area becomes broader and more prominent than is natural. The internal epicondyle is more pointed, and therefore responds more readily to palpation, than the short and blunt external epicondyle. The treatment consists in reducing the fragment by pulling and by retaining it properly by a pad, while the forearm is in flexion ; and then securing with splints or a plaster-of-Paris dressing in a rectangular position. Fig. 50. — Chondro-epiphyseal separation of lower end of humerus in a girl of two years, showing considerable displacement of fragment (two days after the injury). The fracture of the external epicondyle is caused by direct violence as well as indirectly by a fall upon the hand. It is far more frequent than the fracture of the internal epicondyle. The signs consist in the presence of an extravasa- tion, abnormal adduction of the extended forearm, disturbance of function, pain above the epicondyle, crepitus, and the possibility of dislodging the fragment. The latter is frequently pulled upward by the biceps and the antibrachial muscles, which fact renders its SHOULDER AND UPPER EXTREMITY. 117 proper retention in place extremely difficult. It fol- lows too frequently that the fragment becomes attached in a dislodged position, and thus it sometimes becomes an obstacle to the normal motion of the joint. The treatment of the fractured external epicondyle is practically the same as that of its internal fellow. The reduction being more difficult, anesthesia is more frequently indicated to accomplish this purpose thor- oughly. The dressing must be changed every few days. After the elapse of two weeks motion and 51.— Intra-articular fracture of the internal epicondyle in a girl of thirteen years ; slight displacement backward (two days after the injury). massaee treatment should be instituted. If, after two weeks, mobility of the elbow still appears to be arrested, it is advisable to use wire splints, which are bent to the shape of the elbow. They must be changed every day, in order to permit of slight motion. This is done by bending the elbow each day a little more, and accordingly bending the wire splint to the altered shape of the elbow. If the fragment can not be thus retained in proper position, extension by weight in the longitudinal direction of the humerus is to be tried. n8 FRACTURES OF SPECIAL REGIONS. Isolated epicondylar fracture — that is, extra-articular fracture of either the internal or external epicondyle (Figs. 52 and 53) — is caused by direct violence (a fall or blow) or, more frequently, by indirect violence (forci- ble abduction of the arm). The most important sign is the displacement and the mobility of the fragment. There is also circum- scribed extravasation. Pain is absent so long as the Fig. 52. — Extra-articular fracture of left internal epicondyle, showing consid- erable protrusion of the epicondylar fragment and irregular callus formation, which inhibits stretching of the forearm, in a man of thirty-two years (ten weeks after the injury). arm is but moderately moved, but becomes intense when extension and flexion are carried to their limits. The treatment is practically the same as that of the intra-articular type. The extra-articular epicondylar type is sometimes found in connection with outward and inward dislocation. IV. Intercondylar fracture (Fig. 54) is of a severe character. It is either longitudinal or oblique. In the SHOULDER AND UPPER EXTREMITY. II 9 latter event it may be either T- or Y-shaped. The principal sign consists in the possibility of moving the fragments to and fro while palpation is employed. These types are often combined with severe injuries of the soft tissues. The treatment is the same as that of the supracondylar variety. (See p. 108.) In rare cases of non-union the fragment must be exposed and fastened to the surface from which it was detached. In addition, intra-articular separation of the capitnlum humeri (eminentia capitata humeri), which is caused Fig. 53. — Extra-articular epicondylar fractures (after Hoffa). by a fall upon the hand, remains yet to be mentioned. In this injury a small bone- fragment, after being totally severed, is retained as a free body in the joint. It is especially observed in young individuals. The signs of this rare variety are slight abduction in the joint and the presence of an intra-articular exuda- tion. Extension and supination are extremely painful. The severed fragment can generally be palpated be- tween the external epicondyle and the capitulum radii. This injury may be confounded with the fracture of the latter. The diagnosis should always be verified by the 120 FRACTURES OF SPECIAL REGIONS. Rontgen rays. The treatment consists in the excision of the severed fragment. Irregular callus (Fig. 52) is frequently produced in the different varieties of fracture of the lower end of the humerus, and naturally causes considerable functional disturbance in the elbow-joint. In most cases it is due to false coaptation of small bone-fragments. When Fig. 54. — Longitudinal intercondylar fracture in a boy of sixteen years ; impossi- bility of extension (three weeks after the injury). several bone-fragments are severed, as in comminuted fractures, blameless restitutio ad integrum can be ex- pected only from one who is absolutely ignorant of the anatomic relations of the elbow 7 . Many surgeons have suffered innocently for results that, under the grave circumstances, were in reality praiseworthy. But unjust patients hold different views sometimes. What a blessing are the Rontgen rays, especially in SHOULDER AND UPPER EXTREMITY. 12 1 the treatment of this injury, which even under the guidance of the new light offers the greatest difficulties for proper apposition of the fragments! Of course, in such severe cases anesthesia should always be admin- istered during reposition. If, after thorough consolidation, the function of the elbow is prevented — as, for instance, by the protrusion or intervention of a badly united bone-fragment (Figs. 48, 54), or by the interposition of the olecranon be- tween the fragments — removal of the cause by oste- otomy is indicated. The arm is afterward best kept in an extension dressing. In oblique supracondylar fractures oblique coapta- tion often takes place, so that after consolidation the axis of the elbow-joint also becomes oblique accord- ingly. If extended, the elbow shows an angle in either the interior or the inner direction, as the case may be — cubitus valgus or varus. In such cases a perfect cure can be obtained only by severing the badly united area with chisel and hammer. FOREARM. Fracture of the forearm, the extremity used so ex- tensively for working, as well as for protecting the body (this member being instinctively outstretched when one is afraid of falling), is naturally very frequent. It is divided into fracture of the : 1. Ulna (olecranon, coronoid process, diaphysis, styloid process, and fissure above the capitulum ulnae). 2. Radius (capitulum and collum and the typical fracture of the lower end of the radius). 3. Radius and ulna together. Differentiation from dislocation of the antibrachium 122 FRACTURES OF SPECIAL REGIONS. is of great importance. Regarding the fact that there are no less than twelve different types of dislocation of the elbow, the difficulty of contradistinction will be appreciated. The ulna as well as the radius can be dislocated simultaneously toward four different directions : viz., outward and inward as well as forward and backward, the latter type being by far the most frequent. Or the ulna is dislocated backward while the radius is dislo- ■•■ Fig. 55, — Fracture of the olecranon. Diastasis caused by the triceps muscle pulling the upper fragment upward (after Hoffa). cated forward at the same time. The ulna may also be dislocated backward, while the radius may be dislo- cated either forward, or backward, or outward. I. Ulna. — I. Fracture of the olecranon is nearly always caused by direct violence (fall on a stone or the margin of a staircase, or the like). (Figs. 55 and 56.) It is an exceptional occurrence when simple contraction of the triceps muscle produces it. According to surgical text- books, fracture of the olecranon is regarded as rare, SHOULDER AND UPPER EXTREMITY. 123 and it is judged to be less than 1 per cent. But the author's experience, supported by the Rontgen rays, has convinced him of the fallacy of this view, which is sanctified by its ancientness only. In the author's own experience, four cases of fracture of the olecranon process were discovered by skiagraphy among the material of his surgical clinics during a period of six months only. These cases represented a percentage of 8 among all the fractures observed Fig. 56. — Fracture of the olecranon. Moderate degree of diastasis in a boy ot fourteen years (four days after the injury). there in that time. Admitting that this percentage was in part accidental, this fresh experience cer- tainly points to a percentage higher than that usually assumed. In two of the cases the author was not sure that he had to deal with a fracture of the olecranon until he had been informed by the aid of the Rontgen rays. It must naturally be seen that in the pre-Rontgenian era surgeons would have failed to register such cases 124 FRACTURES OF SPECIAL REGIONS. among the fractures of the olecranon. The author's experience furthermore contradicts the widely spread opinion that the fracture of the olecranon does not happen before the fifteenth year. It is observed from the tenth year, when the nucleus for ossification appears. The fracture is almost always caused by direct vio- lence upon the posterior portion of the elbow. In two cases there was but little diastasis, while in two others it was considerable. The line of fracture in each ot these cases was transverse, three of the fractures being of the simple type and only one being comminuted. Signs. — If the point of the insertion of the extensor muscles of the forearm is severed entirely, active ex- tension is rendered impossible. The triceps muscle pull- ing the upper fragment upward, more or less diastasis is produced. (Fig. 55.) Crepitus is seldom absent. There is a circumscribed extravasation, — as a rule, of a globular shape, — which so covers the line of frac- ture that its presence may not always be readily dis- covered. In such instances it is only by deep palpa- tion that the line is to be detected. If the fragments are still kept in contact by the peri- osteum little or no diastasis may exist. Consequently, there will be no crepitus. It is especially in this fortu- nate event that the fracture is liable to be overlooked. It is evident that such cases give an excellent prognosis under any treatment. But if there is diastasis, bony union may remain an exception. Still, even in these examples, if the fragments remain near together bony union once in a while takes place. Usually, however, fibrous union is all that can be expected ; but this is generally so firm that in the majority of cases the function of the elbow remains but little impaired. A Manual of MODERN SURGERY. By J. Chalmers Da Costa, M.D., Pro- fessor of Practice of Surgery and Clini- cal Surgery, Jeffer- DA COSTA'S SURGERY son Medical College, Philadelphia; Surgeon to the Philadelphia Hospital, etc. Handsome octavo, 911 pages, co- piously illustrated. Cloth, $4.00 net; Half Morocco, $5.00 net. J- & & NEW AND ENLARGED EDITION The remarkable success attending Da Costa's Manual of Surgery, and the general favor with which it has been received, have led the author in this revision to produce a complete treatise on modern surgery along the sam'e lines that made the former edition so successful. The Reviews of the First Edition. " We know of no small work on surgery in the English language which so well fills the require- ments of the modern student." — Medico-Chinir- gical Journal, Bristol, England. " Essentially practical in its scope, judicious in its advice, and likely to prove of value to the student." — New Yurk Medical Journal. book has been entirely rewritten and very much enlarged. The old edition has long been a favorite not only with students and teachers, but also with practising physicians and surgeons, and it is believed 'hat the present work will find an even wider field of usefulness. <£* <£ <£ <£ For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. A Manual of MODERN SURGERY. By J. Chalmers Da Costa, M.D., Pro- fessor of Practice of Surgery and Clini- cal Surgery, Jeffer- DA COSTA'S SURGERY son Medical College, Philadelphia; Surgeon to the Philadelphia Hospital, etc. Handsome octavo, 9 \\ pages, co- piously illustrated. Cloth, $4.00 net; Half Morocco, $5.00 net. J- J> J> NEW AND ENLARGED EDITION The remarkable success attending Da Costa's Manual of Surgery, and the general favor with which it has been received, have led the author in this revision to produce a complete treatise on modern surgery along the same lines that made the former edition so successful. The Reviews of the First Edition. " We know of no small work on surgery in the English language which so well fills the require- ments of the modern student." — Medico-Ckirnr- gical Journal, Bristol, England. " Essentially practical in its scope, judicious in its advice, and likely to prove of value to the student." — New York Medical Journal. book has been entirely rewritten and very much enlarged. The old edition has long been a favorite not only with students and teachers, but also with practising physicians and surgeons, and it is believed * hat the present work will find an even wider field of usefulness. «£* <£* <£* •£ For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. SHOULDER AND UPPER EXTREMITY. I 25 The treatment consists in the application of a plaster- of-Paris splint in the hyperextended position while the displaced fragment is tightly grasped and pushed downward by the fingers of an assistant. The turns of the bandage are conducted around the pressing fingers in such a manner that at last a wall is formed around the digital impressions, which, after having become dry, so holds the reduced fragment in place that return of the piece is rendered impossible. (Com- pare Treatment of Fracture of the Patella.) In simple cases the extension dressing can be changed into the rectangular after the lapse of about two weeks. After four weeks motion and massage must be employed. In the event of considerable ex- travasation, aspiratory puncture under thorough asep- tic precautions is advisable before reduction is at- tempted. If all these points are carefully observed, suturing the fragments needs to be resorted to only in case of extreme diastasis and in compound fractures of the olecranon. The technic of wiring the fragments is essentially the same as in fracture of the patella. Separation of the epiphysis of the olecranon is rare, and is to be viewed from the same standpoint as the fracture. It should be remembered that the epiphysis joins the diaphysis in the seventeenth year. II. Fracture of the coronoid process of the ulna is mostly caused by indirect violence (fall on the outstretched hand and forearm). It represents a rare type. (Fig. 57.) The signs are depression at the olecranon, so marked that the ulna appears to be dislocated back- ward. But the position of the radius, which remained unchanged, always differentiates the fracture from the dislocation. (Compare Fig. 45.) Further signs are the 126 FRACTURES OF SPECIAL REGIONS. intense pain felt when the process is touched, the crepitus, and the impossibility of extending the fore- arm to its limit. Palpation of the fragment is gen- erally prevented by the thickness of the muscles that run over the fractured area. This fracture type is sometimes combined with back- ward dislocation of both bones of the forearm. The treatment consists in reposition of the frag- ment, which is done by forcible pulling on the forearm. The arm then is flexed at an acute angle and immo- Fig- 57- — Fracture of the coronoid process of the ulna (after 1 1 off a bilized in this position by splints. When the swell- ing has subsided, a plaster-of-Paris dressing should be applied. After the lapse of two weeks the position is gradually changed until extension can be made. Passive motion and massage must be resorted to after three weeks. In most cases, on account of the diastasis of the fragments, a fibrous union is all that can be looked for. Still, the function of the elbow is usually but little impaired even in this event. When there is an abun- dant callus proliferation, the function of the joint is SHOULDER AND UPPER EXTREMITY. 127 apt to suffer. In such cases the projecting bone-mass must be chiseled off. III. Fracture of the diaphysis of the ulna (Figs. 58 and 59) is nearly always caused by direct violence (a fall or a blow warded off with the elevated antibrachium). The seat of the fracture is generally below the middle of the bone, where its diameter is smallest and the bone has the least muscular protection. The signs are generally well marked, since the ulna appears to be folded inward at the point of fracture. There is ecchymosis, local pain, abnormal mobility, and crepitus. Usually, there is also an extravasation Fig. 58. — Exterior view of fracture of the diaphysis of the ulna. surrounding the seat of fracture. Sometimes the signs are insignificant, as in the case illustrated by figure 60. The treatment consists in the adaptation of two splints, reaching from the wrist to the elbow, after reposition has been accomplished by a strong pull. After adjustment and dressing, the position of the arm may be rectangular, and the forearm should be carried between pronation and supination. In cases of soft callus (Fig. 61), sometimes occurring in childhood, immobilization must be kept up for months. Sometimes the shaft fractures at the upper third, in 123 FRACTURES OF SPECIAL RECIONS. which case it was taken for granted that this injury was always combined with a dislocation of the capitulum radii. But, as the Rontgen rays show in figure 62, such fractures happen without injuring the radius. As will be seen later, in our account of the lower end of the radius, as well as in that of malleolar fracture, disloca- Fig. 59- — Fracture of ulnar diaphysis, showing slight displacement, in a man fifty years of age (four days after the injury). In spite of the inward displace- ment, and consequently the slight anterior bending of the radius, the symptoms were insignificant. The man (truckman) always attended to his heavy work. The moderate pain was attributed to contusion, and therefore no immobilization had been attempted. tion or fracture of either bone of the forearm generally follows the reception of any amount of violence strong enough to displace the fragments of its broken fellow. Therefore it was a priori assumed that whenever con- siderable displacement in ulnar fractures is found, either fracture or dislocation of the radius will be present at the same time. SHOULDER AND UPPER EXTREMITY. I29 The treatment of fracture of the ulna at its upper third is essentially the same as that for fracture of any other portion of the ulnar diaphysis. Particular care, however, should be taken in this variety to exert slight pressure upon the capitulum radii by applying an ad- hesive plaster pad. If the displaced fragment is pressed against the Fig. 60. — Well united fracture of diaphysis of the ulna in a woman thirty-six years of age (ten days after the injury). radius, consolidation may take place. (Fig. 63.) In this event supination becomes impossible. At an early stage reposition under anesthesia may be successfully tried, but later on osteotomy has to be resorted to. IV. Isolated fracture of the styloid process of the ulna is rare, and is caused by direct violence. The fragment 9 HO FRACTURES OF SPECIAL REGIONS. can always be distinctly felt underneath the integu- ment, and since it can easily be grasped, its proper reduction can always be accomplished. To retain it well, an adhesive plaster pad must be applied over the fractured area. The dressing must immobilize the elbow as well as the wrist for at least two weeks, Fig. 6l. — Fracture of the lower end Fig. 62. — Fracture of the diaphysis of the ulna in a boy of twelve years, of the ulna. Slight displacement in a showing soft callus formation (three child of two years (two days after the weeks after the injury). injury). since there is great tendency to displacement — an event that might be followed by the formation of pseudarthrosis. Fracture of the styloid process of the ulna occurs, in the great majority of cases, in connection with fracture of the lower end of the radius. SHOULDER AND UPPER EXTREMITY. 131 The treatment is essentially the same as that for fracture of the lower end of the radius combined with fracture of the styloid process of the ulna. (See p. 154.) V. Fissure of the capitulum ulnae is found in connec- tion with the classic fracture of the lower end of the Fig. 63. — Fusion of radius and ulna nine weeks after fracture of the ulna, render- ing supination impossible, in a man of thirty-three years. (Compare Fig. 69.) radius, as demonstrated first by the author. :i: (Fig. 85.) This phenomenon was never recognized until the Ront- gen rays taught its presence. In the author's cases the line of infraction has always been transverse. * See " The Rontgen Rays in Surgery," " International Medical Magazine," May, 1897. [ 32 FRACTURES OF SPECIAL REGIONS. The symptoms of its presence are so insignificant that it can be well understood why in former times no attention was ever paid to it. 2. Radius. — I. Fracture of the head of the radius (Figs. 64 and 65) is generally caused by indirect violence (fall upon the outstretched hand when in pronation). Direct violence (blow upon the head of the radius) produces it but exceptionally. Sometimes Fig. 64. — Fracture of the head of the radius in a man thirty-two years of age ; skiagram taken through plaster-of- Paris wire splint twelve hours after the in- jury. There was considerable outward displacement, which was believed to have been reduced after the dressing was applied, but the skiagram, taken after the dressing was completed, showed that displacement was still present. (Compare Fig. 65.) there is only an infraction, in which case the diagnosis could not be made without the aid of the Rontgen rays. Contusion or distortion is usually suspected in such cases. Its character is naturally intra-articular. It is, like the fracture of the radial neck, observed as an isolated fracture as well as in combination with one of the other bony elements of the elbow. If there is a complete fracture, abnormal mobility is always present, and there is also intense pain at the GRIFFITH ON THE BABY THE CARE OF THE BABY. By J. P. Crozer Griffith, M.D., Clinical Professor of Diseases of Children, University of Pennsylvania ; Physi- cian to the Children's Hospital, Philadelphia, etc. Octavo. 404 pages. Illustrated. Cloth, $1.50. SECOND EDITION, REVISED. The author has endeavored to furnish a reliable guide for mothers anxious to inform themselves with regard to the best way of caring for their "The best book for the use of the young mother with which we are acquainted. There are very few general practitioners who could not read the work through with advantage." — Archives of Pediatrics. children in sickness and in health. He has made his statements plain and easily understood, in the hope that the volume may be of service " The whole book is characterized by rare good sense, and is evidently written by a master hand. It can be read with benefit not only by mothers but by medical students and by any practitioners who have not had large opportuni- ties for observing children." — American Journal of Obstetrics. not only to mot'.ers and nurses but also to med- ical students and to practitioners whose oppor- tunities for observing children have been limited. For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. NERVOUS AND MENTAL DIS- EASES. By Archibald Church, M.D., Professor of Clinical Neu- rology, Mental Diseases, and Medical Juris- CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES prudence, Northwestern University ; and Frederick Peterson, M.D., Chief of Clinic, Nervous Department, College of Physicians and Surgeons, New York. Handsome octavo, 843 pages, with over 300 illustrations. Cloth, $5.00 net; Half Morocco, $6.00 net. SECOND EDITION. This book is intended to furnish students and practitioners with a practical, working knowl- edge of nervous and mental diseases. Written by men of wide experience and authority, it will present the many recent additions to the subject. The book is not filled with an ex- tended dissertation on anatomy and pathology, but, treating these points in connection with special conditions, it lays particular stress on methods of examination, diagnosis, and treat- ment. In this respect the work is unusually complete and valuable, laying down the defi- nite courses of procedure which the authors have found the most generally satisfactory. J For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. SHOULDER AND UPPER EXTREMITY. 1 33 seat of the fracture. Crepitus is perceived by turning the hand alternately in pronation and supination. The treatment consists in the application of an immobilizing dressing in the position of extreme flexion, in order to relax the biceps muscle, a pad being attached over the fractured area. Immobili- zation must be kept up for at least three weeks, in order to avoid the recurrence of displacement. Pre- mature contraction of the biceps muscle might sep- Fig. 65. — Fracture of the head of the radius. Same case as that shown in figure 64. Displacement corrected in the extended position (four days after the injury). arate the replaced fragments. If the fragments should not be properly retained in place, the production of extensive adhesions might demand resection of the radial head. Sometimes small fragments separated from the car- tilage remain detached, and act like foreign bodies, so as to disturb the function of the elbow. In such cases their removal may be indicated. In the rare event of laceration of the radial nerve, neurorrhaphy is indicated. 134 FRACTURES OF SPECIAL REGIONS. Epiphyseal separation occurs in infants and young children in a small number of cases. It is caused by holding their hands up or by swinging them. The treatment is the same as that of fracture of the radial head. II. Fracture of the neck of the radius is still rarer fig, 66. — Fracture of the neck of the radius in a man thirty years of age. Moderate deformity, but small longitudinal splinter adhering to the lateral sur- face by fibrous tissue, causing functional disturbance (nine years after the injury). than that of its head. Its etiology is the same. The signs are also similar, the only difference consisting in the impossibility of turning the radial head to and fro during pronation and supination in cases of frac- ture of the neck. A bony projection may also be found in the latter event. SHOULDER AND UPPER EXTREMITY. 1 35 The treatment is the same as that of the fracture of the radial head. The radial nerve may become lacerated by a splinter of bone (Fig. 66), in which case removal of the splinter, under the use of the Rontgen rays, is indicated. The same nerve may become embedded in a callus- mass (Fig. 67), in which event it must be freed by chiseling off the abundant callus. III. Fracture of the shaft of the radius (Fig. 68) is caused by violence, either direct (blow upon the arm) or indirect (fall on the hand). It is rare. The signs consist in displacement, abnormal mobility, Fig. 67. — Radial nerve thickened and embedded in callus-tissue (after Oilier). and localized pain. Crepitus is perceived whenever pronation and supination are exercised. The treatment consists in thorough reposition and the application of an upper and a lower splint in supi- nation. Immobilization should be extended over the elbow as well as the wrist. If reposition is imperfect, the interosseal space may be filled up by callus forma- tion, and a consequent fusion with the ulna would occur, which would render pronation and supination impossible. (Fig. 69 ; compare Fig. 63 as counter- part.) In such event separation by operative interfer- ence would be indicated. J 6 FRACTURES OF SPECIAL REGIONS. IV. Typical fracture of the lower end of the radius (erro- neously called Colles' fracture) is the most frequent fracture type, and is supposed to form at least eighteen Fig. 68. — Fracture of the shaft of the radius without displacement in a woman twenty-eight years of age. Slight callus formation (seventeen days after the injury) ; also showing signs of well-united fracture of the lower end of the radius, sustained six years earlier. Fig. 69. — Fracture of the shaft of the radius in a man thirty-six years of age, showing considerable displacement, the upper fragment riding upon the lower, thereby causing functional disturbance (one year after the injury). per cent, of all fractures. In the author's estimation it figures with twenty-two per cent. It is caused by a fall upon the hand while in dorsal extension. The very strong ligamentum carpi volare profundum being SHOULDER AND UPPER EXTREMITY Si more resistant than the spongious end of the bone, it is evident why, as first demonstrated by Nelaton (Fig. 70), that structure never breaks, and that a radial fracture can be the only result. In no fracture type have the Rontgen rays disclosed so many errors as in this much-disputed fracture. It can safely be maintained that in most cases skiagraphy has revealed conditions that were not expected and that have required the original di- agnosis to be more or less modified. The question most frequent- ly asked of a surgeon : " How do you treat Colles' fracture? " or " Do you use long or short splints ? Do you prefer the plaster-of- Paris dressing or splint, or are you fond of Dum- reicher's, Roser's, Schede's, Braatz's, Gordon's, Kolliker's, Moore's, Carr's, Bond's, Mid- deldorpf's bilateral, or the old pistol splint of Nelaton ? Are you in favor of immobiliza- tion or of early motion ? " etc., show that fracture of the lower end of the radius is reearded as of a con- stant type, uniformly characterized by the fracture of the bone about an inch above the articulation, and fol- lowed by a silver-fork-shaped deformity of the wrist. This point of view is inadequate and erroneous. It has been found that the anatomic aspects of the various forms of fracture of the lower end of the Fig. 70. — Fracture of the lower end of the radius and of the styloid process of the ulna. The ligamentum carpi volare is much strained, but is still coher- ing. 138 FRACTURES OF SPECIAL REGIONS. radius differ in fact more than those of any other frac- ture; and it is self-evident that such variants are by no means of indifferent importance in respect to treat- ment. For a simple fracture, for instance, and for a Y-shaped intra-articular fracture, different therapeutic means must necessarily be sought. Again, the vary- ing relations of the fracture of the radius to its fellow, the ulna, are of great practical importance. Since March, 1896, when the author first began to skiagraph all his cases of fracture and suspected fracture, until recently, he has observed fracture of the Fig. 71. — Chondro-epiphyseal separation in an infant. lower end of the radius sixty-two times. In a num- ber of cases fissure of the ulna coexists, as was first reported by him. Another surprising feature is that simultaneous fracture of the styloid process of the ulna has been found in a great number of cases, a complication that was formerly supposed to be of extremely rare occurrence. It is but natural that our views should be changed by fuller clinical experience and anatomic observation. Without undervaluing the great work of our surgical masters before the Rontgen era, the rays furnish the SHOULDER AND UPPER EXTREMITY. 1 39 most convincing proof of the necessity of modifying their interpretations of this injury. Thus, having regard to old experience as well as to information gained but recently, the author has tried to classify those different forms of this much-disputed fracture that appear to be most characteristic, and must ac- cordingly demand different therapeutic measures ; and if we bear in mind the frequency of fractures of this type, the importance of the discussion will be evident. In classifying the different varieties of fracture of the lower end of the radius it is essential to distinguish : (a) Epiphyseal separation. (6) Fissures (infractions). (c) Complete fractures. (d) Incomplete fractures. (e) Fractures of the lower end of the radius com- bined with infraction or fracture of the head of the ulna. {/) Fractures of the lower end of the radius com- bined with fractures of the styloid process of the ulna. All these different varieties may be extra-articular as well as intra-articular. (a) Epiphyseal separation of the lower end of the radius shows the same symptoms and has to be treated on the same principles as the complete fracture. The bicycle enthusiasm is responsible for a greater frequency of the separation of the lower epiphyses in young adults. In very young children there are real chondro- epiphyseal separations (Fig. 71), in which the epiphyseal cartilage is sharply severed from the osseous end of the diaphysis ; while later, at the age of between four- 140 FRACTURES OF SPECIAL REGIONS. u u — 2 ~ _& R V oj CJ H H CJ >. 6 CI CJ p cj Bi bJO p — CJ a "3 > £ ,C in CJ CJ CJ ?. — -r Bj OS V 3 c 5. t/) c^ OS s £ «-> ^^ CI CJ c bfl US u u > CJ 5 5/. 11 'H p KS H 5j 03 >b E 3 M sj d r^ 7^ OS 0H CJ p eS i- a; a! "c3 -r cj — -3 CJ OS }-t ^g CJ O ;:/ es Oh CJ ej ,Q S u> OJ cd CJ -r OJ VI U CJ 'c ? ns c^ ? a CJ 5, w c/i js >- CJ CJ CJ oj : M os J3 OJ ss a ,— p u c ^ -z 'w ~ q <*H "5 a •"5 H O u 5 5 :7 si i-l CJ CJ OS CJ > si -r CJ <<-, £ p c CJ t/1 c_ _>■. ^o pi cu t/i OJ ~ 1^ ij ni bJO 6 u Kl Oh CJ E rT CJ en .2 si CJ SHOULDER AND UPPER EXTREMITY. I 4 I teen and seventeen, osteo-epiphyseal separation is ob- served, the fracture-line not being strictly limited to the epiphyseal cartilage, but extending to the diaphysis. The latter variety occurs more frequently than the first one, which is extremely rare. (See Fig. 72, right hand.) There is a great tendency to rapid union in children. Sometimes, however, the growth of the radius becomes arrested, notwithstanding the accom- plishment of a perfect union. Fig- 73- — Eissure of the lower end of the radius, one inch above the epi- physeal cartilage, in a boy fourteen years of age (one week after the in- jury). Fig. 74. — Fissufe of the lower end of the radius in a man thirty-four years of age. Small splinter protruding toward the ulna (eight hours after the injury). (b) Fissures {infractions') (Figs. j$, 74) are extra-artic- ular as well as intra-articular, and are far more frequent than was supposed before the discovery of the Ront- gen rays. In former times fissure has doubtless been often treated as distortion or contusion, espe- cially when only small splinters were broken off. (Fig. 74). No displacement being present, it is easily un- derstood why such injuries often healed under any treatment. Sometimes these cases, not being rec- ognized in their true light, gave a better prognosis 14- FRACTURES OF SPECIAL REGIONS. than those which were properly diagnosticated, but in which the limb had been immobilized during- too loner a period. The line of infraction in these cases is either trans- verse (as in Fig. J3) or longitudinal (Fig. 74), so that the bone appears as if divided into halves ; or it is irregular in shape, generally resembling a star. In such cases the bone is divided into several still coher- ing portions. The signs are severe pain and slight swelling at the seat of infraction. Abnormal mobility and crepitus being absent, the diagnosis of contusion or distortion is obviously often made. Treatment. — No displacement being present, no re- duction is required. This explains why the results in these cases are nearly always good, no matter what sort of treatment is employed. In fact, if they are treated by a quack, whose ignorance leads him to treat the injury as a sprain, with an ointment, a poultice, or "faith," a better result may sometimes be obtained than by the learned surgical neophyte, who, after a most erudite diagnosis, immobilizes the joint for a long period in his zeal to keep the imaginary fragments together. Of course, no deformity will result, but adhesions may form in the neighboring joint or in the sheaths of the tendons, and the wrist may become stiff and immobile. In such a case a patient who was not treated at all — in other words, whose hand was not immobilized, so that he could constantly use it — would, in fact, escape unpleasant consequences. In cases in which the Rontgen rays prove the exis- tence of a fissure beyond a doubt, a wire splint which is slightly bent downward is to be applied at the SHOULDER AND UPPER EXTREMITY. 1 43 flexor side of the arm, where it reaches from the tip of the fingers to the elbow, the downward bent portion of the splint being attached to the palm of the hand. If there is much swelling, the dressing must be kept moist with Burow's solution. (Compare pp. 48 and 67.) After three or four days, when the swelling has sub- sided, this long splint must be removed, and a bracelet, consisting of a piece of moss-board, is applied instead. The width of this bracelet should be about four inches, its middle corresponding to the wrist. This appliance immobilizes the wrist sufficiently, and at the same time it permits enough motion to counteract the formation of adhesions in the sheaths of the tendons. The patient carries his hand in a sling in such a manner that the ulnar margin rests on it. Thus, free motion of the hand is permitted. The patient is told to move his fingers, as in playing the piano. The author also finds it very useful to advise the patient to grasp mar- bles of moderate size and to roll them around in the palm of the hand. Patients generally are willing to keep these marbles in their pockets and play with them while reading or conversing or walking around. If motion is thus kept up constantly, massage treat- ment as well as forcible motion can be dispensed with in this fracture type. (c) Complete fractures, the most frequent varieties of fractures of the lower end of the radius, must also be subdivided into intra-articular and extra-articular. The intra-articular variety is the most important, since it is always complicated with more or less grave injuries to the joint-surfaces. (Fig. 75.) The line of fracture is generally oblique, but sometimes nearly longitudinal. The tendency to displacement 144 FRACTURES OF SPECIAL REGIONS. is particularly marked in this form. Still, abnormal mobility, and crepitus accordingly, are but seldom noticeable. Since there is generally a well-marked extravasation, which may extend even over the sheaths Fig. 75. — Complete intraarticular fracture (Y-shaped) of the lower end of the radius, in a woman of forty years, showing lateral as well as median displace- ment of fragments (two hours after the injury). of the tendons, palpation is rendered extremely diffi- cult and uncertain. Massage has to be employed early, in order to remove the extravasation, when sometimes the margins of the severed fragments can be grasped. Further valuable signs of fracture, like SHOULDER AND UPPER EXTREMITY. 1 45 deformity, caused by the displacement, may also be veiled on account of the extravasation. It goes with- out saying that another sign of fracture, severe local pain, is never absent. From a consideration of all these points it becomes evident that a detailed diagnosis of this type is pos- sible only by the aid of the Rontgen rays, which show us, also, just how the displaced fragments are to be reduced. Sometimes reduction can be done prop- erly only when an anesthetic is employed. Forcible extension for the purpose is contraindicated because it would increase the traumatic synovitis always present in this variety. The severed fragments are readjusted best by gentle grasping manipulations. An adhesive plaster pad is applied over the displaced fragment after reduction is accomplished, and moderate pressure until slight agglutination has taken place. This may be expected after a few days. Then further pressure can be dispensed with. Otherwise the treatment is the same as that of the extra-articular variety. (See p. 148.) Among all the different types of fractures of the lower end of the radius the intra-articular is the most serious. Only the continuous control, by the aid of the Rontgen rays, of the proper situation of the fragments will give good results. The extra-artictdar complete type is the best known among the varieties of this fracture. (Fig. 76.) Having been first described by Colles, it is called Colles' frac- ture in this country as well as in England. It is gen- erally transverse, and so has the character of a supra- condyloid fracture. Its seat is generally about ^ of an inch above the articulation, where the compact A. Fig. 76. — Extra-articular fracture of the lower end of the radius (Colles' fracture) in a young man of twenty years. A. Showing inward displacement and impaction (twelve days after the injury). B. Displacement reduced (three weeks after the injury). fig. 77- — Complete extra articular fracture of the radius (Colles' fracture), show- ing bayonet shaped deformity (anterior view). 146 SHOULDER AND UPPER EXTREMITY. 147 tissue of the cliaphysis passes over into the cancellated spongiosa. Signs. — Displacement always being present in this type, the deformity is highly characteristic. In most cases the direction of the displacement is upward, so that there is a dorsal promi- nence. In such cases the shape of the deformed wrist resem- bles that of a bayonet or a fork, for which reason Colles' fracture has also been called silver-fork fracture {displacement a la four- chette). (Figs, yy, 78.) By thus being upwardly dislodged, the epiphyseal portion is brought into slight supination, while the diaphysis is in decided prona- tion. The epiphysis being in very close connection with the ulna, the latter is slightly pushed toward the ulna if the ligamentous connection between the radial fragment and the ulna remains intact. This phenomenon finds its conspicuous expression in the lateral prominence of the styloid process of the ulna. Sometimes the tendency of epiphyseal displacement is toward the opposite side or downward, and the deformity appears accordingly in that direction. (Compare Figs. 79, 80, 81.) In the first case the direction of the displacement was never recognized in the pre-R6ntgen era. Abnormal mobility Fig. 78. — Complete extra- articular fracture of the lower end of the radius (Colles' fracture) showing bayonet- shaped deformity (posterior view). 148 FRACTURES OF SPECIAL REGIONS. is always present to a greater or lesser extent, and consequently there is always crepitus. In examining the patient a firm support must be ob- tained for the injured hand, the latter being kept down on a plane by an assistant, and the epiphyseal frag- ment being grasped. Inspection invariably detects the characteristic abnormal prominence, while palpation is Fig- 79- — Downward displacement in extra-articular fracture of lower end of the radius in a man thirty years of age (two days after the injury). A. Anterior view. B. Lateral view. often able to outline the shape of the fragment. The local pain is generally severe. In the rare event of impaction of the epiphyseal end into the upper end of the radius, abnormal mobility and crepitus are absent. Treatment. — The first requirement, accurate reduc- tion, may be carried out with little difficulty by forced extension, the hand being grasped as in a firm hand- shaking, with downward pressure by the surgeon's SHOULDER AND UPPER EXTREMITY. 149 thumb, while counterextension is used on the forearm, which is flexed rectangularly. If an assistant is at hand, the surgeon grasps four fingers with his left, and Fig. 80. — Extra-articular fracture of the lower end of the radius in a woman forty- five years of age, showing sideward displacement (one day'after the injury). Fig. Si. — Extra articular fracture of the lower end of the radius in a woman forty-five years of age. Skiagram of same case as figure 80, showing fragment displaced toward the ulna, thus causing the slight projection. the thumb with his right, hand, while the assistant uses counterpressure at the elbow. (Fig. 83.) If this pro- cedure should fail, anesthesia must be employed. 15° FRACTURES OF SPECIAL REGIONS. Keeping the fragments well adjusted in a proper position is quite difficult sometimes. The author has, however, always been able to secure this by very simple methods. A long adaptable wire splint (see p. 97) is applied while forced traction is made ; the splint reaches at the flexor side of the arm from the tip of the fingers to the elbow. If the direction of the dis- placement is upward (silver-fork shape), a pad of adhesive plaster is attached to the dorsal integument above the fragment. Then a short, narrow splint of wood is applied on the dorsal aspect of the arm, reaching from the metacarpopha- langeal joint to four inches above the wrist, and is kept pressing down by the application of a gauze ban- dage. If the tendency of the displace- ment is downward (Fig. 79), the same procedure is carried out in the opposite manner, the wire splint being applied on the dorsal and the wooden splint and pad on the palmar side of the arm. If the displacement be sidewise (Figs. 80, 8 1 ), which is most marked when there is a simultaneous injury of the ulna, the immobilization must be carried out on entirely different lines. The adhesive plaster pad must then be applied laterally to the fragment, two Fig. 82. — Extra-articu- lar fracture of the lower end of the radius in a woman forty-five years of age. Immobilization in plaster-of-Paris dressing after the reposition of the displacement. SHOULDER AND UPPER EXTREMITY. J 5i long, narrow wooden splints being used at the same time. One of these splints, being a little broader than the diameter of the bone, begins at the metacarpo- phalangeal joint of the thumb, and the other at the same point of the little finger. Both extend up to the elbow, the same as the long wire splint. If there should be any displacement in the opposite direction, the pad must be applied on the ulnar side. No dorsal splint is used in this variety. After the dressing is finished, the skiagram verifies the proper position of the fragments. In case the tendency to displacement : Jll>- Fig. 83. — Forcible reduction. can not be overcome, a plaster-of-Paris dressing is applied (Fig. 82), while forcible extension and counter- extension are used. (Fig. 83.) Whether the position of the fragments is correct should be ascertained by the rays after the plaster-of-Paris dressing is applied. (Fig. 84.) If there be much swelling, wet applications may be advantageously used by pouring Burow's solution upon the gauze bandage, the wire splint permitting pene- tration of the fluid. (Compare pp. 48, 67.) If after the lapse of a week agglutination of the frag- 152 FRACTURES OF SPECIAL REGIONS. tnents is obtained and no deformity is evident, then the soft tissues must receive consideration. It is only then that short splints are in order. They consist of well- padded pieces of wood, extending from the metacarpo- phalangeal joint up to the middle of the forearm. After another week a bracelet, such as is recommended for the treatment of simple fissure (p. 142), is so applied as to permit of free motion of the fingers. The patient is also told to move his fingers as in playing the piano, Fig. 84. — Extra-articular fracture of the lower end of the radius in a woman thirty-five years of age ; skiagram taken through the plaster-of- Paris dressing (two weeks after the injury). also to use the marbles, as described in the treatment of the fissure. After the third week massage treatment is indicated, active as well as passive motion of the joint being employed at the same time. The results of these simple methods are just as good as, if not better than, those obtained by the numerous most complicated apparatus often advised for the same purpose. If all the points of these manipulations dictated by simple AMERICAN POCKET MEDICAL DICTIONARY THE AMERICAN POCKET MEDICAL DICTIONARY. Edited by "W. A. Newman Dorland,A.M.,M.D., Assistant Obstetrician to the Hospital of the University of Penn- sylvania; Fellow of the American Academy of Medicine, etc. Over 500 pages. Full leather, limp, with gold edges. Price, $1.00 net; with patent thumb index, $1.25 net. SECOND EDITION, REVISED. This is the ideal pocket lexicon- — It is an absolutely new book, and not a revision of any old work. — It is complete, defining all the terms of modern medicine, and forming an unusually full vocabulary. — It gives the pronunciation of all the terms. — It makes a "One of the handiest lit'le dictionaries for the pocket that we have ever seen. Its definitions are short, concise, and complete, so that it contains within a small space as many words, satisfactorily- defined, as are found in some of the much larger volumes." — American Medico-Surgical Bulletin. special feature of the newer words neglected by other dictionaries. — It contains a wealth of anatomical tables of special value to students in preparing for examinations. — The new or "reformed" spelling is employed. — A handy volume indispensable to every medical man. & For sale by all Booksellers, or sent post-paid on receipt of price. W\ B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. AMERICAN POCKET MEDICAL DICTIONARY THE AMERICAN POCKET MEDICAL DICTIONARY. Edited by "W. A. Newman Dorland,A.M.,M.D., Assistant Obstetrician to the Hospital of the University of Penn- sylvania; Fellow of the American Academy of Medicine, etc. Over 500 pages. Full leather, limp, with gold edges. Price, $1.00 net; with patent thumb index, $1.25 net. SECOND EDITION REVISED. This is the ideal pocket lexicon. — It is an absolutely new book, and not a revision of any old work.— It is complete, defining all the terms of modern medicine, and forming an unusually full vocabulary. — It gives the pronunciation of all the terms. — It makes a "One of the handiest litile dictionaries for the pocket that we have ever seen. Its definitions are short, concise, and complete, so that it contains within a small space as many words, satisfactorily defined, as are found in some of the much larger volumes." — American Medico-Surgical Bulletin. special feature of the newer words neglected by other dictionaries. — It contains a wealth of anatomical tables of special value to students in preparing for examinations. — The new or "reformed" spelling is employed. — A handy volume indispensable to every medical man. Jt For sale by all Booksellers, or sent post-paid on receipt of price. W". B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. SHOULDER AND UPPER EXTREMITY. OO common sense are observed, and if their proper exe- cution is certified by the skiagram, surgical clinics will no longer furnish so much testimony of deformities and functional impairment following fracture of the lower end of the radius. In cases of severe functional disturbance of the joint produced by the agglutination of the fragments in a displaced position the author has repeatedly succeeded in reducing the deformity by osteotomy. In every case the functional result has been very satisfactory. (e) Fractures of the lower end of the radius combined Fig. 85. — Extra-articular fracture of the lower end of the radius combined with irregular fissure of the head of the ulna ^ of an inch above the epiphysis in a woman twenty-nine years of age (one day after the injury). with fissure or fracture of the head of the ulna (Fig. 85) are of moderate frequency. This combination was entirely unknown before the Rontgen discovery. It was the privilege of the author to call attention to its existence first.* Since that time he has observed it in eleven per cent, of his cases of fracture of the lower * See "The Rontgen Rays in Surgery," Magazine," May, 1897. International Medical *54 FRACTURES OF SPECIAL REGIONS. end of the radius. This surprising experience was corroborated by Kahleyss.* In case of fissure of the ulna no displacement is present and the symptoms are essentially the same as those of the complete fractures described on page 148. In the much rarer event of complete fracture of the ulna the symptoms of sideward displacement are well pronounced. This combination is the main cause of the impairment of supination and pronation. The treatment is the same as that of complete frac- Fig. 86. — Fracture of the lower end of the radius combined with fracture of the styloid process of the ulna in a man thirty-eight years of age (two days after the injury). tures connected with sideward displacement (see p. 150), sideward pressure by attaching an adhesive plaster pad over the ulnar fragment after reduction being well kept up. (f) Fracture of the lower end of the radius combined with fracture of the styloid process of the ulna (Fig. 86) is extremely frequent. In the author's cases this com- * " Beitrag zur Kenntniss der Fracturen am unteren Ende des Radius," " Deutsche Festschrift fiir Chirurgie," 12. November, 1897. SHOULDER AND UPPER EXTREMITY. 155 bination represents thirty-two per cent, of all cases of fracture of the lower end of the radius. In this variety the radio-ulnar joint is always more or less involved. The treatment is the same as that of the complete fractures connected with sideward displacement, side- ward pressure by attaching adhesive plaster pads over Fig. 87. — Excessive callus formation after extra-articular fracture of the radius in a boy fifteen years of age, followed by considerable disturbance in pronation and supination (four months after the injury). Fig. 88. — Excessive callus for- mation after extra-articular fracture in a girl sixteen years of age. No functional disturbance (three weeks after the injury). the fragments after reduction being rigidly maintained. In obstinate cases the resection of the process is some- times indicated. In case of functional disturbances caused by ex- cessive callus formation osteotomy has to be resorted to. (Fig. 87.) Simple deformity not connected with any functional disturbance would not indicate chiseling off the callus. (Fig. 88.) IS6 FRACTURES OF SPECIAL REGIONS. Deformities causing severe disturbances of the func- tion of the wrist may be corrected by performing oste- otomy in the radial fracture-line. Sometimes, in ad- dition, a wedee must be exsected from the ulna in order to permit of perfect reposition. If rotation is impossible, the head of the ulna should be resected. The author's experience comprises four such cases, in persons of thirty-three to forty years, in Fig. 89. — Fracture of radius and ulna in a boy nine years of age. Angular displacement not reduced ; abundant callus formation beginning (six weeks after the injury). which osteotomy gave gratifying results. Adults who must support themselves by the work of their hands should invariably be subjected to radical operative cor- rection. Only aged persons should be exempted. 3. Fracture of Radius and Ulna Together. — Simultaneous fractures of radius and ulna are of mod- erately frequent occurrence and are caused by direct as well as by indirect violence. Especially in early childhood, where the typical fracture of the radius is SHOULDER AND UPPER EXTREMITY. 157 rare on account of the soft condition of the epiphyseal end of that bone, a fall on the outstretched hand pro- duces the fracture of both bones. Sometimes there is only an infraction, if children are exceptionally con- cerned. The centers of both diaphyses are most liable to fracture. It is only by direct violence (falling of heavy objects, gunshot wounds) that the other portions of the bones of the forearm become fractured. The signs are generally well marked. Displace- Fig. 90. — Fracture of radius and ulna (green-stick variety) in a boy twelve years of age, showing cohering periosteal and osseous portions. No ulnar and only slight radial displacement (two days after the injury). ment always being present, the bones form a slight anterior or posterior angle. (Fig. 89.) If, as it hap- pens in children, there are still cohering portions of periosteum and bone, the displacement may be insignificant. (Fig. 90.) There is intense pain, ab- normal mobility, and loss of function. Sometimes the displacement is so great that the fragments overlap. Then considerable shortening of the arm will be 158 FRACTURES OF SPECIAL REGIONS. noticed. (Fig. 91.) Sometimes one of the two bones is only fissured ; then there is but little displacement, as a rule, in the other. (Fig. 92.) The treatment consists in the application of long wooden splints, after reduction has been accomplished by forcible extension and counterextension. The very wide, well-padded splints (one on the flexor and one on the extensor side) must reach from the metacarpus up above the elbow, the hand being kept in supination. Fig. 91. — Fracture of radius and ulna in a man thirty-nine years of age, showing overlapping of fragments (eight weeks after the injury). This position prevents fusion of both bones (ossi- fication of the ligament). After the lapse of a week a plaster-of-Paris dressing can be applied, while the elbow is in the rectangular position. After three weeks, massage treatment, active and passive motion, especially rotatory manipulations, are instituted. In intrauterine fracture of the radius and ulna wir- ing of the bones has to be resorted to. In the case illustrated by figure 93 (see also Figs. 1, 2) the author has succeeded in uniting the fragments in this manner. SHOULDER AND UPPER EXTREMITY. I 59 Pseudoarthrosis of the antibrachium is rarer than that of the humerus. It is also caused by the intervention of muscular tissue. It is especially the upper third whose anatomic conditions seem to favor it. If one portion of the arm is in pronation and the other one in supination, the separation of the fragments may be- come so great that the upper end of the radial frag- ment unites with the lower one of the ulna. Such conditions can be remedied only by osteotomy. If the Fig. 92. — Fracture of the radius combined with fissure of the ulna — slight axial displacement of the radius — in a man twenty-two years of age (ten days after the injury). radius is concerned at its upper third, its deep situa- tion causes considerable technical difficulties for opera- tion If radius and ulna grow together laterally, so that a bridge is formed that fills the interosseal space, supina- tion is prevented. Compare figures 63 and 69 as counterparts. Then the division of the bridge by the use of a chisel or a Gigli wire saw is indicated, the arm being immobilized in supination afterward. In compound fractures the question of amputation i6o FRACTURES OF SPECIAL REGIONS. often arises. As previously emphasized in Part I of this book, conservative principles should be upheld to the utmost. Sometimes under the most unfavorable circumstances — extensive comminuted fractures and necrosis, laceration of the flexor and extensor muscles, necrosis of a large skin-portion — still fairly good func- tion of the extremity is finally obtained. Loose bone-splinters must be removed and sharp edges should be cut away with bone-shears. Lacer- ated tendons must be trimmed and carefully united Fig. 93. — Intrauterine fracture of radius and ulna, united by osteorrhaphy, in a boy of three months. Radial wire extracted ; ulnar wire still in situ (four weeks after operation). with thin formalin catgut. Necrotic skin-portions must be exsected. Skin-grafting should not be attempted before there is a normally granulating surface. As long as there is much reaction, a wire splint should be applied in vertical suspension, which method permits of the permanent application of an antiseptic lotion. (Compare section on Compound Fractures, p. 67.) When the swelling has subsided and the suppuration has become scant, a moss splint or a fenestrated plaster-of-Paris dressing should be chosen. The series of books included under this title are translations into English of the world-famous "Lehmann medicinische Handatlanten." For scientific accuracy, pictorial beauty, compact- ness, and cheapness SAUNDERS' MEDICAL HAND-ATLASES these books surpass any similar volumes ever published. Each volume contains from 50 to J00 col- ored plates, executed by the most skilful German lithographers. 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Volume I. ready in April, For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. SHOULDER AND UPPER EXTREMITY. 161 HAND AND FINGERS. Fracture of the bones of the hand and finders are classified as follows : i. Fracture of the carpus. 2. Fracture of the metacarpus. 3. Fracture of the phalanges. Fracture of the carpus is extremely rare and is always caused by direct violence (fall of heavy objects). Fig. 94. — Supracondylar fracture of first metacarpus of the little finger, showing inward displacement (thus also resembling dislocation), in a man twenty- eight years of age (two weeks after the injury). The ligaments connecting these bones being very strong, the displacement is insignificant, and therefore the fracture often escapes notice unless a skiagram is taken. Abnormal mobility and crepitus naturally being ab- sent, pain and functional disturbance are the main signs. This fracture is generally combined with severe injuries of the soft tissues. The treatment consists in applying a palmar wire splint. Immobilization is properly combined with the l62 FRACTURES OF SPECIAL REGIONS. application of antiseptic lotions, especially if there be simultaneous injuries to the soft tissues. In the event Fig. 95. — Fracture of right fourth metacarpus, showing displacement, in a man thirty years of age (two d.iys after the injury). Fig. 96. — Dorsal dislocation of the thumb (outer view) in a boy of twelve years (four weeks after the injury). of a compound comminuted fracture of a carpal bone, its removal is indicated. After the lapse of ten days massage treatment and active and passive motion are in order. SHOULDER AND UPPER EXTREMITY. 16 Fracture of the metacarpus (Fig. 94), especially of the first metacarpal bone, is very common, and is also Fig- 97- — Dorsal dislocation of the thumb. Skiagram of figure Fig. 98. — Lateral dislocation of thumb in a girl eight years of age (six weeks after the injury). produced by direct violence. The interosseous mus- cles pulling the upper fragment downward, some slight 164 FRACTURES OF SPECIAL REGIONS. displacement can always be noticed. (Fig. 95.) There is also abnormal mobility, crepitus, local pain, and swell- ing. As the Rontgen rays have demonstrated, a large Fig- 99- — Dorsal dislocation of the second phalanx of the thumb in a woman thirty years of age (sixteen months after the injury). Fig. 100. — Supracondylar fracture of the first phalanx of the little finger in a lad of twenty years (two days after the injury). numberof allegeddislocationsand contusions are, in fact, separations of the phalangeal epiphyses in childhood. The treatment is essentially the same as that of the fracture of a carpal bone, the only point to be specially SHOULDER AND UPPER EXTREMITY. 165 considered in this injury being that an adhesive plaster pad should be placed on the palm at the seat of the fracture. Massage must be commenced early. In the excep- tional case of considerable displacement wiring of the fragments may come into consideration. Fracture of the phalanges is nearly always caused by direct violence (the fingers being caught or held in a door, etc.). Exceptionally, it is produced by indirect violence (fall on the fingers or overextension during wrestling, etc.). The signs are typical, and, in fact, so apparent that they should hardly need description. Still, fracture is sometimes confounded with dislocations. As to contra- distinction, compare figures 96, 97, 98, and 99. The treatment consists in keepino- the fragments well r & & Fig. 101. — Splint for phalangeal immobilized by Small Splints fracture (after Hoffa). of wood or pasteboard (Fig. 101), after thorough reduction is accomplished. The splints are to be fastened by starched gauze bandages. Union is generally perfect in two weeks. If the fracture be comminuted or compound, ex- treme conservatism should prevail. It is surprising how often a shattered phalanx is entirely restored to its function under thorough aseptic precautions. The severed fragments being removed, sometimes all that is left of the phalanx is represented by a thin bony frag- ment ; nevertheless, this may develop into a useful phalanx again, provided enough periosteum is left in its place. 1 66 FRACTURES OF SPECIAL REGIONS. FRACTURES OF THE PELVIS AND THE LOWER EXTREMITY. PELVIS. Fractures of the pelvis represent less than one per cent, of all fractures, and are similar to those of the skull and thorax, inasmuch as they occur in an osseous ring, irregularly composed of several bones : namely, the os ilii, the os pubis, the os ischii, and the sacrum Fig. 102. — Fracture of pelvis, fragments boring into ileopsoas muscle (after Hoffa). and coccyx. They concern either one of these bones individually or the pelvic ring as a whole. (Fig. 102.) They are generally caused by direct violence, as, for instance, by a heavy weight falling upon the pelvis, or by the patient falling from a high point, or by his being crushed between the buffers of two railroad-cars while they are being coupled, or by the passage of a wagon- wheel across the lower abdomen. In the first event — -fracture of an individual pelvic PELVIS AND LOWER EXTREMITY. \6j bone — palpation will always reveal separation ot at least a single fractured bone-portion. Abnormal mobility, displacement, and consequently crepitus, are always present. The abdominal organs are but sel- dom injured. The treatment consists in reposition as far as is pos- sible, and immobilization by applying a long splint extending from the external malleolus to the axilla. (Compare Fig. 103.) Union in a deformed position, while, of course, undesirable, is seldom followed by any functional disturbance. Fractures of the pelvic ring are always to be re- Fig. 103. — -Long splint applied during extension, in fracture of the pelvis or the neck of the femur. garded as of importance, since they are generally accompanied by simultaneous injuries either of the abdominal viscera or of the urethra, the sciatic nerve, or the femoral vessels. The signs consist in ecchymosis, localized pain, which is severely intensified on pressure, inability to lift the lower limb, and marked displacement. In all cases of suspected pelvic fracture the rectum and urethra must be carefully explored also. In trying to press both iliac bones together an intense circumscribed pain is produced, which may direct attention to the point of fracture. 1 68 FRACTURES OF SPECIAL REGIONS. Laceration of the urethra as well as abdominal in- juries are treated upon general surgical principles. In urethral injuries permanent catheterization should be employed. It is the significance and extent of these concomitant injuries that determine the course of this dreaded fracture type. The best treatment consists in the application of a plaster-of- Paris dressing surrounding the abdomen, pelvis, and thigh (Fig. 1 1 6), or in the application of a long splint. (Fig. 103.) Extension also sometimes proves useful. (Fig. 10.) THIGH. Fractures of the thigh represent about six per cent, of all fractures. They are divided into those of the upper end, those of the diaphysis, and those of the lower end of the femur. In adults they generally occur in the lower, and in aged persons in the upper, end, while in children the middle third is most fre- quently involved. They occur, however, in any part of the bone in children. Fracture of the Upper End of the Femur. — Fracture of the upper part of the femur concerns either its head or neck or the trochanteric region. Anatomically, it is to be divided into epiphyseal sepa- ration of the upper end of the femur, in fracture of the neck (intra- and extracapsular), the isolated frac- ture of the trochanter major, and the infratrochanteric fracture. I. Epiphyseal separation of the upper end of the femur occurs before the twentieth year, and is extremely rare. The epiphysis being intra-articularly situated, it is ob- vious that it is but seldom reached by an injury. As PELVIS AND LOWER EXTREMITY. 1 69 a rule, this fracture is produced by a sudden wrench or sprain. The signs consist mainly in abnormal mobility, in- tense local pain, and soft crepitus. There is also shortening- and elevation of the trochanter major above Nelaton's line. It is easily confounded with dislocation, hip-disease, or infantile paralysis. It is often overlooked until the patient commences to walk. Ununited fracture may cause lameness. The treatment is the same as that of a fracture of the femoral neck. In ununited fracture operative in- terference is indicated. (Compare section on Wiring the Bones, p. 70.) II. Fracture of the neck of the femur seldom occurs before the fiftieth year of life, and may be caused by direct as well as by indirect violence (fall upon the hip, blow upon the trochanter major). The line of fracture is either in the intertrochanteric line or at the femoral head, or between these points. Its direction is either transverse or oblique to the axis of the neck. Accord- ingly, intra- and extracapsular fractures of the neck of the femur are distinguished, analogous to the frac- tures of the anatomic and surgical necks of the humerus. [a] Intracapsular fracture (Fig. 104) is most fre- quent in aged persons, a prevalence that is explained by the senile changes at the angle of the thigh-bone. While in earlier life the angle of the neck to the shaft is still oblique, it becomes rectangular in elderly people. Thus the bone becomes more fragile, so that it may fracture even after trifling injuries, such as, for instance, simply falling on a carpet. The line of fracture is transverse and is generally 170 FRACTURES OF SPECIAL REGIONS. indentated, so that impaction is greatly favored. Sometimes there is only infraction. The signs of intracapsular fracture are but little marked if there be infraction or impaction, so that no displacement is produced. The only signs would then be the local pain and functional disorder of the leg, so that contusion of the hip may be thought of. Fig. 104. — Intracapsular fracture in a man fifty-five years of age, showing absence of osseous union ; head appearing to be free in the acetabulum. Fibrous union permits of limited amount of motion (two years after the injury). In such cases elucidation by the Rontgen rays is urgently required. If there is displacement, the signs are very distinct. Then the lea- is rotated outward and is shortened to the extent of at least an inch. Crepitus and pain are also then present. If the fracture be not caused by a fall upon the hip, PELVIS AND LOWER EXTREMITY. 171 ecchymosis, if present at all, will be insignificant. The pain is severe on the seat of fracture and increases if the thigh is flexed. Crepitus is absent. Treatment meets with great difficulties. These are caused, in the first place, by the poor chance of approximating the fragments, the diastasis of which is increased by the intracapsular blood extravasation. The upper fragment, the sole connection of which is the ligamentum teres, has but a poor arterial supply. The osteoblasts, which regenerate new bone-tissue from the spongious portion of the bone only, are scant, since there is merely a cartilaginous coat ; and callus formation is consequently poor. The most favorable outcome to be looked for is therefore a superficial approximation of the fragments by a few fibrous bands. Another and still more important difficulty is pre- sented by the general condition of the patients, who are usually aged, and therefore inclined to hypostatic pneumonia when condemned to a prolonged sick-bed. It is especially here that the ambulatory plaster-of- Paris dressing shows its great advantages. (See p. 43.) This dressing is applied at once after the integu- ment is well oiled. Reposition is made after the leg is surrounded first by an ordinary plaster-of-Paris dressing from the metatarsus up to the knee. It is then easy to reduce the fragment by pulling on the foot, while counterextension is exercised on the pelvis. The patient's trunk and pelvis are elevated throughout the time when this procedure is carried out. Now around the tubera ossis ischii and the trochanter a seating-ring is formed, which, after being hardened, is connected with the dressing of the lower end. This is accomplished by many turns of plaster-of-Paris ban- 172 FRACTURES OF SPECIAL REGIONS. dages, below which a thin wooden fiber for firmer sup- port is interposed. (Fig. 6.) Patients are sometimes able to pfo about on crutches as early as two days after the fracture was sustained. It is needless to call attention to the fact that in each case the circulation is likely to be well kept up and the danger of hypostasis in the lungs is often counteracted. If for any reason the ambulatory dressing can not be applied, Buck's extension (see Fig. 10), in connection with a long extension splint (see Fig. 103), must be employed. Great care should then be taken that no pressure is made upon the sacrum, where decubitus may become detrimental. The position of the upper parts of the body must be frequently changed and the patient should be ad- vised to sit up in bed frequently and to inspire deeply in order to avoid circulatory stasis. Where reposition is found to be impossible, and the displacement is of considerable extent, uniting the fragments with ivory pegs has repeatedly been sug- gested. While the idea of this procedure is irre- proachable from a theoretic standpoint, it can not be indorsed, because it has shown unsatisfactory results in practice. In several cases it was also followed by fatal consequences. It is self-evident that in cases of infraction and impaction, where naturally there is no displacement, the results are in general most satisfactory. (5) Extracapsular fracture of the neck of the femur (Fig. 105) is generally produced by direct violence (fall upon the hip or blow on the trochanter major). The direction of the fracture is usually in the intertrochan- teric line. PELVIS AND LOWER EXTREMITY. 17, The fracture may be incomplete, in which event it is only the posterior cervical portion that is clearly divided, while the thicker anterior portion shows infrac- tion only. Much more frequently the fracture is complete, in which case the trochanter as well as the head of the Fig. 105. — Extracapsular fracture of the neck of the femur (after Hoffa). femur may be so involved that there are several dis- tinct fragments. The signs are ecchymosis, shortening, and outward rotation. In impaction (Fig. 106) the shortening sel- dom exceeds iy£ inches; but if there is no impaction, the shortening may amount to four inches. Another important sign — the higher situation of the trochanter i/4 FRACTURES OF SPECIAL REGIONS. major — can be elicited by measuring the distance from the anterior superior spine to the knee, which is found shorter than that of the uninjured extremity. If there is any displacement, crepitus can be de- tected invariably. Local pain, tenderness, and swell- ing are also seldom absent. Ordinarily, there is entire loss of function ; but in impacted extracapsular frac- Fig. 106. — Extracapsular fracture of the neck of the femur in a woman twenty-six years of age ; considerable functional disturbance (two months after the injury). tures it has repeatedly been observed that the patients were able to walk a short distance. The diagnosis of this fracture type may become difficult if neither shortening nor rotation of the leg be present, and the case may be mistaken for one of simple contusion. Looking for crepitus in such cases seems, as a rule, to be inadvisable ; since the rotatory PELVIS AND LOWER EXTREMITY. I 75 manipulations necessary for eliciting it might be apt to separate the impaction — an event which would at least make a bad matter worse. And even in cases in which shortening and rotation were well marked, dis- location instead of fracture has been diagnosticated. It is true«that a certain similarity to iliac dislocation exists, but the latter can be always excluded, for the reason that the femoral head can not be found outside of the acetabulum. It should furthermore be consid- ered that in a fracture of this kind the patient is unable to elevate his leg by active flexion ; while in dislocation passive motion would be arrested to a much higher degree than in fracture. In summing up the main points of differentiation it should be considered that in dislocation the femoral head can be palpated in the buttocks. In dislocation there is also a moderate amount of resistance when motion is made, while in fracture there is little or none. In dislocation the upper portion of the hip-joint is flat- tened, while in fracture there is no change of the nor- mal contours. If the trochanter appears widened and enlarged, the chances are that the patient fell upon the trochanter, which fact would point to a fracture. In old age fracture is the rule. Bony union, while exceptional in the intracapsular type, is the rule in the extracapsular variety, callus proliferation generally being abundant. Sometimes the callus is so rich that free articular motion becomes impeded. (Fig. 107.) Union generally becomes perfect in six weeks, after which the function of the extremity is seldom found to be disturbed, even if shortening to the extent of an inch has occurred. 1/6 FRACTURES OF SPECIAL REGIONS. Fig. 107. — Impacted extracapsular fracture of the neck of the femur in a man fifty-eight years of age (three years after the injury), causing considerable functional disturbance on account of the excessive callus proliferation around the seat of the fracture, especially around the major trochanter. PELVIS AND LOWER EXTREMITY. 177 The principles of treatment are the same as those for the intracapsular fracture of the neck of the femur. III. Isolated fracture of the trochanter major (Fig. 108 a and b) is always produced by direct violence, and is of rare occurrence. By being pulled backward and upward by the gluteal medius and minimus muscles the tro- chanter appears considerably displaced. The trochan- ter major is also sometimes separated in persons under the age of seventeen years. The signs are sometimes insignificant, and may Fig. 108. — Isolated fracture of trochanter major, a. Exterior view ; b, showing diastasis (after Hoffa). point to a contusion, since the function of the leg is little, if at all, disturbed ; inward rotation of the leg being possible by the action of the tensor fasciae latse muscle, and outward rotation by that of the obtura- tores, gemelli, and quadratus femoris. There is, of course, no shortening such as occurs in fracture of the femoral neck. Flattening of the trochanteric area is often noticed. The displaced fragments being nearly always palpable, differentiation from simple contusion should be easy. 178 FRACTURES OF SPECIAL REGIONS. The treatment consists in immobilization of the leg- between two sand-bacrs in outward rotation and abduc- Fig. 109.— Spiral infratrochanteric fracture in a boy of twelve years (fourteen hours after the injury), showing but little sideward displacement. tion, while the hip and knee are slightly flexed. In this position reduction of the displaced fragment is PELVIS AND LOWER EXTREMITY. 1 79 accomplished to the nearest extent possible. An ad- hesive plaster compress, to be kept in situ by an adhesive plaster strip, should be applied above and behind the fragments. In children a larcre abdominofemoral dressing, con- sisting of plaster-of-Paris, is recommended. (Fig. 115.) IV. I nfratrochanteric fracture (Fig. 109) — that is, frac- ture just below the trochanter — is caused either by indi- rect violence (torsion of the body while falling down), causing a spiral-shaped line (Fig. 109), or by direct violence (blow or fall), which would cause a trans- verse line. It is prevalent among the hard-working classes, and generally concerns adults. The signs, besides those found in ordinary fractures, are the tilting upward of the upper fragments by the ileopsoas and glutaei muscles, which are inserted below the trochanter. This characteristic phenomenon ex- plains why the upper fragment is sometimes put into a right anorle to the femoral axis. In rotatino- the femur it will be found that the trochanter does not go along with the motion, abnormal mobility being found only below the trochanter. The treatment requires reposition and extension in a flexed position ; otherwise it is treated after the same principles as the fractures of the neck of the femur. Fracture of the Diaphysis of the Femur. — Fractures of the diaphysis of the femur are far more frequent than those of the neck. Of all femoral frac- tures, which figure at six per cent, among all fractures, they represent seventy-one per cent., while those of the neck amount to twenty-nine per cent. only. They are caused either by direct or indirect violence or by mus- i So FRACTURES OF SPECIAL REGIONS. cular action. Most of these fractures are caused by a downfall from a considerable height. The line of fracture is generally oblique, if the middle and upper thirds of the shaft are concerned ; but in the lower third a transverse direction is the rule. Sometimes a lonoq- tudinal fracture-line branches off from the transverse one into the knee-joint (T-fracture). These transverse Fig. no. — Infratrochanteric fracture in an infant of ten months. No effort at reposition was made during the first three weeks after the injury. Union took place with considerable deformity and slight functional disturbance. fractures are especially frequent in children, who may sustain them in consequence of comparatively slight violence. Rickety children have a special predilec- tion for this variety. The prognosis is very good in childhood, union generally being perfect in from three to four weeks. Simultaneous injuries to the femoral artery and vein PELVIS AND LOWER EXTREMITY. I»I are by no means rare complications of this fracture type. The signs of fracture of the diaphysis are, first of all, ecchymosis, intense pain, and entire loss of function. With the exception of the rare cases where the perios- teum remained partly intact, or where indentation of Fig. III. — Fracture of the diaphysis of the femur in an infant six months of age, showing slight riding of fragments (two days after the injury). the fractured ends keeps them fixed together, much deformity is always present. (Fig. 1 1 1.) This is caused by the considerable degree of displacement more or less characteristic of this injury. It is naturally fol- lowed by another conspicuous symptom : namely, the extreme shortening, which in some cases amounts to as much as six inches. Generally, the lower fragment 182 FRACTURES OF SPECIAL REGIONS. is rotated outward and pulled upward and to the inner and outer side of the upper one. In fracture of the upper third the upper fragment is drawn upward and outward by the action of the ileopsoas and glutaei mus- cles, while the lower one is drawn inward and upward by the action of the adductor muscles. Thus riding of Fig. 112. — Typical oblique fracture of diaphysis at the upper third of the femur, showing considerable displacement and intervening of muscular tissue, in a boy seven years of age (twenty-four hours after the injury). the fragments is produced (see Fig. 112), so that they show an angle. (Also compare Fig. 1 14.) In the middle third the upper fragment is drawn before the lower one and outward from it, if the line of fracture is situated above the insertion of the ad- ductor muscles ; but if it occurs below that point, the upper fragment is directed forward and inward. PELVIS AND LOWER EXTREMITY. 1 83 The same principle as to displacement applies to all fractures of the lower third. It scarcely need be said that such extensive displacement is always accompa- nied by abnormal mobility, and that crepitus is never absent. The shortening of the leg is always consider- able. The rough edges of the upper fragment are generally easily palpable above the patella, where it often pierces the tendon of the quadriceps muscle, while the lower fragment is felt in the popliteal space. It is also obvious that in T- or Y-shaped fractures of the lower third of the shaft synovitis, due to extravasa- tion of blood in the knee-joint, is likely to be caused. In case of indentation of the fragments, an occur- rence that is prevalent in children, displacement, ab- normal mobility, and crepitus are naturally absent, but there is always present another well-marked symp- tom : namely, a pronounced angle at the seat of the fracture. The same rule applies to subperiosteal frac- tures of the shaft. It may be regarded, therefore, as an exception when fractures of the femur can not be diagnosticated by simple inspection. Consequently, the patient can usually be spared the painful manipulations required for eliciting abnormal mobility and crepitus at the time of the first dressinor Union is generally perfect in six weeks. (Fig. 113.) In oblique fractures slight shortening is seldom avoid- able ; but in transverse fractures the normal length of the leg can always be preserved. In case of consider- able shortening, caused by vicious union (Fig. 114), osteotomy is indicated. Compound fractures of the shaft are so grave that before the time of antisepsis they showed a mortality- 184 FRACTURES OF SPECIAL REGIONS. Fig. 113. — Union in fracture of the middle of the femur in a boy of seven years (nine weeks after the injury). In spite of the sideward displacement caus- ing deformity, there is neither shortening nor functional disturbance, which is especially due to the abundance of callus formation. THE HYGIENE OF TRANSMIS- SIBLE DISEASES: their Causation, Modes of Dis- semination, and Methods of Pre- vention* By A. ABBOTT ON TRANSMISSIBLE DISEASES. C Abbott, M.D., Professor of Hygiene and Bacteriology in the University of Pennsylvania ; Director of the Labora- tory of Hygiene. Octavo, 285 pages, with Charts, Maps, and numerous illus- trations. Cloth, $2.00 net. J> £• J> JUST ISSUED. The prevention of disease is one of the most important subjects of the day. With the uni- versal progress in general education, the public is no longer satisfied that a physician enter the house, prescribe his remedies, and depart. They desire more : they wish to know the nature, the origin, and the cause of the sickness, the most likely channels through which the disease is contracted, and the most suitable means for preventing its recurrence or spread. This im- portant and necessary information the present volume seeks to supply. It deals with just that practical portion of the subject which is of vital interest to every intelligent man who has at heart his own best interests as well as those of the community of which he forms a part. «£* ze* zc* v* t£* &^» <& t& &7* t£* For sale by all Booksellers, or sent post-paid on receipt of price. t W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. ANOMALIES AND CURIOSITIES OF MEDICINE. By George M. Gould, A.M.,M.D., GOULD AND and Walter L. Pyle, A.M., M.D. Im- CURIOSITIES ; OF MEDICINE P«ial octavo. 968 1 pages, handsomely illustrated. " Popular Edition f Cloth, $3.00 net ; Half Morocco, $4.00 net. An encyclopedic collection of rare and extra- ordinary cases, and of the most striking instances of abnormality in all branches of medicine and surgery, derived from an exhaustive research of medical literature from its origin to the present day, abstracted, annotated, classified, and in- dexed. As a complete and authoritative Book " A most remarkable and interesting volume. It stands alone among medical literature, an anomaly on anomalies. It is a book full of reve- lations from its first to its last page, and cannot but interest and sometimes almost horrify its readers." — American Medico-Surgical Bulletin. "One of the most valuable contributions ever made to medical literature. Every page is as fascinating as a novel."— Brooklyn Medical Jour- nal. of Reference it will be of value not only to members of the medical profession, but to all persons interested in general scientific, sociologic, and medicolegal topics ; in fact, the absence of any complete work upon the subject makes this volume one of the most important literary inno- vations of the day. <& <£ <£ ^ <£ <£ <£ For sale by all Booksellers, or sent post-paid on receipt of price. "w\ B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. PELVIS AND LOWER EXTREMITY. I8 5 rate of sixty per cent. Nowadays, they usually heal without reaction under the auspices of thorough asepsis. (See p. 51.) It is only in compound frac- tures produced by a very heavy weight (locomotive, Fig. 114. — Vicious union of fracture of femur, showing riding of fragments, in a man fifty- two years of age (nine weeks after the injury). large artillery) that life is jeopardized. In such cases, or when large vessels and nerves are lacerated, ampu- tation offers the only life-saving chance. The treatment consists in reposition by tension and counterextension. Indisputably, a normal position of I 86 FRACTURES OF SPECIAL RFC IONS. the fragments is attainable if the anterior superior spine and the inner margin of the patella and of the great toe are in a straight line. For keeping the frag- ments in this position Buck's extension (from fitteen to twenty-five pounds ; in children a pound for each year), supported by coaptation splints, is the securest procedure. These splints, preferably four altogether, should be placed around the fractured area. 1 hey may consist of wood and must be well padded, and should be fixed to the thigh by adhesive plaster. Adhe- sive plaster strips should next be carried around the knee-joint up to the point of fracture. Counterextension is easily accomplished by elevating the foot of the bed. In children good results can be attained by vertical extension. Although the final results reported of this treatment are excellent, the author is unable to per- suade himself to resort to a method that is sure to cause so much annoyance to the patient. A plaster- of-Paris dressing applied around the abdomen and tlwh while forcible extension and counterextension are exercised, and supported by coaptation splints, gives the same good result (Fig. 1 1 6) ; while at the same time the children can be carried around in this dress- ing, and are therefore but little confined. Even in the quite unnecessary event of pressure-gangrene of the integument of the thigh no serious consequences need be feared, since the muscular layers protecting the femur are extremely thick. (Fig. 115.) In adults the ambulatory dressing is advisable. It should be applied from two to seven clays after the injury is sustained, under the conditions set forth in Part I, where also the technic of application is dis- cussed. PELVIS AND LOWER EXTREMITY I8 7 The principle of the ambulatory dressing is based upon that of the old Thomas splint. (See Fig. 6.) The dressing is supported by the tuber ischii, so that the pelvis is carried and the leg simply hangs down. Fig. 115. — Showing application of abdominal plaster-of- Paris dressing in frac- ture of the diaphysis of the femur in a girl fifteen months of age. The discolor- ation is caused by copal varnish. The modus operandi of application is the same as that in fracture of the neck of the femur. In case of union in a slightly displaced position of the fragments edema extending as far as to the toes i88 FRACTURES OF SPECIAL REGIONS. is often noted. Weeks after perfect consolidation has taken place the patient may limp, and a cyanotic ap- pearance, a sense of frigidity, and cold perspiration are likely to disturb his equanimity. Hot soda baths (a handful of washing soda to a pail of very warm water), hot fomentations overnight, electricity, and Fig. Il6. — Abdominal plaster-of- Paris dressing applied while extension and counterextension are exercised, the patient resting on a hip- and shoulder-rest. massage are indicated in this condition. Massage is especially useful if there be muscular atrophy. If union has taken place in a faulty position, the function of the lower extremity is greatly disturbed. It is the angular type of deformity that is prevalent in fractures of the femur, and that is always followed by considerable shortening, sometimes to the extent of five or six inches, as in the case illustrated by figure 114. PELVIS AND LOWER EXTREMITY. 1 89 In children the fresh callus yields to forcible bend- ing. Thus, without refracturing the femur correction of the deformity under anesthesia is often possible. In adults correction by such a procedure is impossible, consolidation once having taken place. Then, if the function of the extremity is not considerably disturbed, a high shoe may compensate the shortening. But if there is much disturbance of function, osteotomy should be resorted to for radical correction. Refracturing- the deformed bone by pressing it against the edge of the table is permissible in suitable cases. It has all the advantages of the subcutaneous fracture type ; but in most instances the degree of cor- rection obtained is insignificant, the shortening espe- cially being but little affected. In performing osteotomy the incision should be made on the convexity of the deformed area, which must be well exposed by an elevator. Then the line of union of the fragments is severed by means of a strong broad chisel. In old fractures it will often be necessary, in order to straighten the extremity, to resect a wedge from the vertex of the deformed angle. After a large moss dressing has been applied the extremity is put in permanent extension. (See p. 49.) In pseitdarthrosis osteotomy is always indicated, the modus operandi being practically the same as for faulty union, as previously described. The incision must be long, and should be made longitudinally on either the outer or the anterior surface of the thigh. The periosteum must be saved in its entirety, and should therefore also be incised in the longitudinal direction only. After all the intervening tissue has been pushed aside or eventually removed, the bone-ends are fresh- 190 FRACTURES OF SPECIAL REGIONS. ened and united with strong silver wire. Under the most minute aseptic precautions, osteotomy, be it done for faulty union or for pseudarthrosis, is an absolutely safe operation. (Compare aseptic rules, page 52.) Ankylosis (which is generally due to inflammatory processes of long duration) produced by comminuted fractures extending into the knee-joint is easily relieved by forcible motion under anesthesia, provided it exists for a short period only and is of a fibrous nature ; but if it be of an osseous character, any attempt at forci- ble motion may be followed by fatal consequences. /•> "r Fig. 117. — Epiphyseal separation of lower end of femur, a. Complete; b, in- complete. Only an osteotomy performed according to the rules set forth in Part I of this book could remedy this con- dition. In cases of lone standing - , however, where other pathologic changes of the knee-joint have devel- oped (fibrous degeneration, atrophy, etc.), and where the function of the extremity is not too seriously im- paired, operative interference is better dispensed with. (Compare Fig. 119.) Epiphyseal separation of the lower end of the femur (Fig. 117) also deserves mention. It is either complete PELVIS AND LOWER EXTREMITY. I 9 I (Fig. 117 a) or incomplete (Fig. 117 6), is not infre- quent at about the age of sixteen years, and is mainly observed in boys. Its principal cause is, however, overtraction during an obstetric operation. Some- times it is also produced by excessive violence, as, for instance, by having the limb entangled in a revolving wheel. As a rule, it shows some displacement. There Fig. 118. — Normal knee-joint. A. Anterior view in a boy twelve years of age ; note the epiphyseal cartilages ; patella represented by a faint shade only. B. Side view in a man thirty years of age. is always abnormal mobility and soft crepitus. The epiphysis can generally be palpated in its displaced position. In the knee-joint extravasation to a greater or less extent is always found. Pressure and ulcera- tion may lead to secondary hemorrhage, and thrombo- sis may favor gangrene. The principles of treatment are the same as those for the fracture of the lower I92 FRACTURES OF SPECIAL REGIONS. third of the femoral shaft. In case the epiphysis can not be replaced, excision is indicated. Intra=articular separation in the knee still remains to be mentioned. It consists either in a rupture of the semi- lunar cartilages or in the severing of a piece of the femoral end. Rupture of the semilunar cartilages is caused by extensive rotation of the femoral end while the knee is flexed (foot-ball game). The signs are the presence of a movable body in the joint, which disappears during flexion and becomes noticeable during extension. The treatment consists in reposition, if possible, and immobilization by a plaster-of-Paris dressing in exten- sion. In obstinate cases extirpation of the severed cartilage is indicated. Intra=articular severing of a piece of the femoral end is caused by extreme compression of the bones of the knee while the latter is in flexion. The severed piece moves freely in the joint (joint-mouse). The signs are similar to those of the rupture of the semilunar cartilages. The treatment consists in the immediate removal of the cartilage. To appreciate the significance of the various frac- ture types within the sphere of the knee-joint, it is necessary to understand the peculiar anatomic rela- tions of the knee. In the first place, it must be considered that the knee-joint consists of the femoral condyles, the tibial head, and the patella, which form three different articu- lations : viz., one between each tuberosity of the tibia on one side and between each femoral condyle on PELVIS AND LOWER EXTREMITY. 1 93 the other, and one between the femur and the patella. These articulations permit of extension, flexion, and a moderate degree of rotation. The tibiofemoral articu- lations are true condyloid joints, while the femoro- patellar articulations are only of a partly arthroidal character, their mutual joint-surfaces, in fact, not being adapted to each other. (Fig. 118.) PATELLA. Fractures of the patella amount to two per cent, of all fractures, and are far more frequent in the male than in the female. They seldom occur after the age of fifty, and never in young children. Fracture of the patella may be produced by direct as well as by indirect violence. If produced by direct violence (blow on the anterior bone-surface, fall on the anterior portion of the knee-joint, kick of a horse), the soft tissues in the immediate neighborhood are generally more involved than the patella itself. The line of fracture may be transverse, oblique, or longi- tudinal, and its character may be compound or com- minuted. (Fig. 120 a and b.) If produced by indirect violence (muscular action), a transverse fracture is always caused, contraction of the quadriceps muscle fixing the patella while extreme flexion in the knee takes place. So, for instance, if a patient attempts to save himself from falling while making a misstep, by simple reflex the quadriceps is suddenly fixed and the knee-joint is kept in extreme flexion. The signs of fracture of the patella are, in the first place, the separation diastasis of the fragments (Figs. 13 194 FRACTURES OF SPECIAL REGIONS. 121 and 122), the upper one being drawn upward by the action of the quadriceps muscle. (Fig. 123.) The sulcus produced by the diastasis is sometimes as wide as two fino-ers' breadth. The posterior patellar surface forming a part of the knee-joint, it is obvious that there is always more or less considerable extravasation in the knee-joint. It is usually taught that the disturbance of function Fig. 119. — Bony ankylosis of knee in a woman thirty-five years of age. may not be excessive so long as the patient is in an upright position, but that as soon as an attempt at walking is made, the patient would invariably tumble down. But the author's experience shows cases in which, in spite of considerable diastasis, patients were able to walk considerable distances without apparent discomfort. (Compare remarks on Fig. 123.) PELVIS AND LOWER EXTREMITY. 195 If the injury be examined just after the fracture is sustained, crepitus is generally produced, but after- ward the intervention of blood-clots between the frae- ments prevents its production. If the periosteal coat of the patella is preserved intact, there is no displacement, and consequently no crepitus. The same rule holds good in fracture of a small portion of the patella. It is evident that in case of extreme extravasation, when, for instance, the prepatellar bursae are also well filled up, palpation of the fragments becomes so very Fig. 120. — Types of comminuted patellar fracture. difficult that the injury may be mistaken for contu- sion of the knee-joint. With few exceptions union in transverse fracture of the patella, if not sutured, fails to become osseous, fibrous bands filling up the space between the frag- ments. This is obviously due to the diastasis. In such an event the function of the joint is impaired — inability to perform extension and thorough flexion, considerable atrophy of the muscles of the leg, and a greater or less degree of knock-knee being the pre- dominating symptoms. While those who follow a light occupation may not be incapacitated, and may ig6 FRACTURES OF SPECIAL REGIONS. do well by wearing a knee-cap, workingmen may be deprived of their means of making a living by such impairment. In the longitudinal (compare Fig. 1 20 a) or com- minuted fracture type, where no muscular contraction produces any diastasis of the fragments, the union is always osseous. Cases of extreme extravasation show a great ten- dency to the formation of serous intra-articular effusion (hydrarthrosis). Fig. 121. — Fracture of patella. Outer view. The treatment in longitudinal or in partial frac- tures of the patella consists in bringing the fragments into apposition and in proper immobilization by splints or a plaster-of-Paris dressing. Sometimes reposition can be accomplished only after the blood extravasation has been removed by massage. If the exudate be con- siderable, its puncture and its removal by irrigation with a hot normal salt solution may become necessary. This must be done under the most rigorous aseptic precautions. PELVIS AND LOWER EXTREMITY. 197 Regarding the immense importance of such precau- tions, the following points may be emphasized in this connection : In the first place, it must be considered that an in- Fig. 122. — Fracture of patella, showing moderate degree of diastasis, in a woman of thirty-three years (sixteen hours after the injury). jection has the dignity of a surgical operation, and should therefore be viewed from a strictly surgical I98 FRACTURES OF SPECIAL REGIONS. standpoint. Especially should it be preceded by the same preliminary precautions : viz., sterilization of the puncturing apparatus (trocar or aspirator), of the hands of the surgeon, and of the region to be punc- tured. As far as the first point — the apparatus — is con- cerned, it can be safely maintained that ideal asepsis Fig. 123. — Fracture of patella in a man twenty-six years of age, who walked around for one week without being treated. Motion was but slightly arrested; pain almost absent (eight days after the injury). has become an established fact, because all objects that stand boiling well can be rendered aseptic in boiling water, a means accessible everywhere. There is no more excuse for a surgeon to claim that " the poor circumstances of the patient's surroundings did not permit of aseptic precautions." Water, fire, and a boiling-pot can be obtained in the poorest hut, so that the puncturing trocar can easily be sterilized. PELVIS AND LOWER EXTREMITY. 1 99 Since syringes are so constructed that they stand boiling- in a soda solution, the same applies to them. Ordinary hypodermic syringes should never be used for the purpose of aspiration, because they do not stand boiling without being injured, nor do they draw thick fluid. Another objection to them is that their thin needles break easily if they have to be pushed deep down into resistant tissues. As far as the hands of the surgeon and the region to be punctured are concerned, the general rules em- phasized in connection with the treatment of compound fractures are referred to. As mentioned on page 56, that enemy of thorough asepsis, intracutaneous bac- teria, should not be underrated in connection with the question of puncturing. It is evident that in per- forating the skin the sterilized puncturing needle must come in contact with the deep skin-bacteria, which are sheltered by the follicles of the integument, and must thus become a carrier of infection. It is an undeni- able fact that these intracutaneous bacteria can not be destroyed by any chemic or mechanical means of dis- infection. Still, a great deal can be done to lessen the danger of infection by this source. Fortunately, we possess a splendid permeating antiseptic in the tincture of iodin, which, if liberally used, reaches the bacterial shelter — the glands. It is true that, as the bacteriologic experiments of the author have shown, not all intracutaneous bacteria are destroyed by the tincture, cultures having developed on artificial soil. But they failed to develop on an unfavorable soil. It is safe, therefore, to assume that if the surface of the skin is cleaned according to the aseptic rules laid down on page 52, and the region of the area to be 200 FRACTURES OF SPECIAL REGIONS. punctured is painted with iodin tincture, a sterilized instrument in sterilized hands will hardly carry bac- teria into the joint-cavity. In transverse fractures of the patella showing little or no diastasis, a plaster-of-Paris dressing is applied according to the principles laid down for fracture of the olecranon. (Seep. 125.) While the displaced fragment is tightly grasped and pushed downward by the fingers of an assistant, the dressing is applied. The limb is best put in the hyper- extended position, while the patient sits in bed half upright. The turns of the bandage are conducted around the pressing fingers, so that at last a wall is formed around the digital impressions, which includes the reduced fragments after the plaster sets, and be- comes so firm that a return of the fragments proves to be impossible. But if there is considerable diastasis, wiring of the fragments can not too strongly be advocated, since the performance of this simple operation is void of danger in the hands of a surgeon who is master of the princi- ples of asepsis. Whatever has been said of the dan- gers of this operation applies more to the surgical novice, who does not properly understand asepsis, than to aseptic surgery itself. When it is considered that without such operation union becomes only fibrous, and that in the course of time the originally fibrous bands become stretched by the action of the quadri- ceps muscle, so that active extension of the knee- joint becomes impossible, — in other words, that the patient becomes a cripple for life, — we should not refrain from exposing the patient to the trouble of this operation, which guarantees an absolute cure. PELVIS AND LOWER EXTREMITY. 20I Complicated manceuvers, like boring- holes into the fragments, etc., can not be too strongly condemned, since simply conducting a large needle armed with silver wire around the fragments secures their perfect apposition. The needle must be introduced at the upper end into the quadriceps tendon above the patellar margin and through the ligamentum patellae Fig. 124. — Wiring of the patella: placing the silver wire around the frag- ments. Each of the two black semilunar points represents a patellar fragment. The white egg-shaped area between the patellar fragments belongs to the anterior surface of the external femoral condyle. on the lower margin of the lower fragment. (Fig. 124.) The silver wire is twisted above the middle of the fracture line, its ends protruding at last through the suture line of the integument. (Fig. 125.) A semilunar incision should be made from one epi- condyle to the other, just above the insertion of the 202 FRACTURES OF SPECIAL REGIONS. ligamentum patellae. Thus a convex flap is formed, which is dissected backward. The fractured area is then fully exposed, and the intra-articular blood extra- vasation can be freely reached. An iron-clad principle, especially referring to this operation, is, " Hands off the joint ! " For the consolation of such suroeons as are afraid Fig. 125. — Patellar fragments (Fig. 124) united by a silver wire suture. of the aseptic state of their own fingers it may be said that there is no need for coming into contact with any portion of the field of operation with their fingers or hands. The needle can be carried through with the aid of a needle-holder and the twisting, which in itself tends to bring the fragments together, can be done with a forceps. The blood-clots can be removed by powerful irrigation with a hot sterile salt solution. PELVIS AND LOWER EXTREMITY. 203 For powerful and thorough irrigation, intended for the mechanical removal of such material as may be apt to offer a favorable soil for the development of bacteria (tissue-shreds, blood-clots), an operating-table (Fig. 5) that is provided with pans is of great conve- nience. Fig. 126. — Wire broken three weeks after the operation, the nervous patient having jumped out of bed during the night. Immediate recurrence of diastasis. After the suturing (preferably done with boiled for- malin catgut) is completed, either an ordinary wound dressing, supported by a large moss splint, or a fenes- trated plaster-of-Paris dressing (the fenestra being created by holding a sterilized glass over the wound — 204 FRACTURES OF SPECIAL REGIONS. see Fig. 5) is applied. The wire suture is carefully removed after three weeks. Then the knee is well immobilized for two or three weeks longer, and the patient is allowed to walk about in this dressing. The wire must be very strong, for there is risk of its breaking if the patient be restless. (Fig. 126.) The operation can be performed immediately after the acci- dent, but may just as well be deferred for a few days if extravasation is abundant. In view of the absolute certainty of success in this operation, the principle of which was advanced by one of the greatest surgical geniuses of all time, Volkmann, it appears rather strange that procedures like the treat- ment with Malgaigne's hook, which remind one of the relics in the torture chambers of Nuremberg, still find their devoted partizans. Compound fractures of the patella are treated after the same principles as are set forth in Part I. (P. 51.) In the event of atrophy of the quadriceps muscle, which is extremely frequent after the non-operative treatment of the patellar fracture, faradization and massage are indicated for a lone time. LEG. It is assumed that fractures of the leg constitute about sixteen per cent, of all fractures. They occur predominantly between the ages of thirty and sixty, but are rare in childhood. Some of our former views on fractures of the leg were also radically shaken by the Rontgen rays, and most of our knowledge had to be greatly modified. As in fractures of the lower end of the radius, fissures PELVIS AND LOWER EXTREMITY. 205 and fractures that formerly were entirely unknown were found to be of frequent occurrence. Fissures as well as comminuted infractions had been overlooked in the pre-R6ntgen era, because they showed no ten- dency to displacement. Another essential point re- vealed by the Rontgen rays is that in many instances the injury itself, and particularly the extent of the displacement, was much more serious than was to be expected from ordinary means of examination or by judging from the degree of the deformity. They are classified best as epiphyseal separation, simultaneous fracture of the tibia and fibula, and frac- ture of either tibia or fibula individually. Epiphyseal separation is observed in individuals under twenty. The etiology, signs, and treatment of this injury fall under the same considerations as those of the fractures of the same type, so that a separate description seems unnecessary. Separation of the tubercle of the tibia, sometimes occurring in children, is treated on the same principles as fracture of the patella, for which, moreover, it is, as a rule, mistaken. Simultaneous fractures of the tibia and fibula are subdivided into fractures of the upper and middle portions and into fracture of the lower end. Simultaneous fractures of the tibia and fibula at their upper and middle portions are generally produced by direct violence (passage of a wagon-wheel, falling of a heavy weight, kick of a horse). The predilection is for the middle third, while the upper portion is but rarely involved. It is less frequent in children than fracture of the femur. If produced by indirect violence (fall from a high 206 FRACTURES OF SPECIAL REGIONS. point, misstep on slippery ground), the fracture of the tibia is always below that of the fibula, the tibia being- broken first and the fibula then giving way higher up. The line of fracture is generally oblique or spiral, the transverse variety being found but exceptionally. Indentation is a frequent occurrence. Compound fractures are extremely common in this sphere, a fact well explained by the situation of the an- terior tibial surface directly underneath the integument. The signs are always well marked, a circumstance also explainable by the superficial situation of the tibia, whereby sideward displacement is made dis- tinctly perceptible. There is also outward rotation of the limb and an angular protrusion of the crest of the tibia. The fibular fragments appear less conspicuous, since their protection by the peroneal muscles makes their palpation somewhat more difficult. But the short- ening and the marked abnormal mobility prove the simultaneous fracture of the fibula beyond a doubt. In the far less serious event of indentation, dis- placement, abnormal mobility, and crepitus are natu- rally absent, the signs being limited to intense local pain and loss of function. The treatment consists in reposition by extension on the foot, which is held rectangularly, and by counterextension on the knee. Under this manipula- tion shortening disappears at once. Protrusion of the upper fragment is counteracted by elevating the heel in order to draw the lower fragment downward and forward. Still more effectual is counterpressure exer- cised by a weight, which should be attached to the area of the upper fragment. If the inner margin of the PELVIS AND LOWER EXTREMITY 207 patella is in line with the inner side of the ball of the great toe, the position is correct. The best chances for keeping the fragments in proper apposition are offered by the plaster-of-Paris A. Fig. 127. — Fracture of diaphysis of tibia and fibula. A, Pseudarthrosis relieved by wiring; wire of tibial fragments still in situ : B, non-union, fragments wired three months after the injury. dressing, which is applied while extension, counterex- tension, and counterpressure are exercised. (Compare Figs. 5, 116.) If padding is well done, there is no fear of the supervention of pressure gangrene. If the case can not be kept under daily control, and especially if 208 FRACTURES OF SPECIAL REGIONS. the patients be unintelligent, or if there be much ten- sion and swelling, splints are preferable. The ambulatory dressing (compare Fig. 6), in which the patient can walk about on crutches, can be applied after from four to seven days. The modus operandi Fig. 128. — Supramalleolar fracture in a man fifty-eight years ot age. Although displacement was apparently slight, filling-up of the interosseal space causes great functional disturbance (two years after the injury). consists in applying, after the skin is well oiled, a solid plaster-of-Paris dressing from the metatarsus up to the lower third of the thigh. The support is furnished by the femur and its condyles. The sole of the dressing is fortified by inlaying with strips of tin, zinc, or wood. PELVIS AND LOWER EXTREMITY. 200, It is amazing- how many fractures of the leg, even in these clays, heal with more or less deformity. Pseudar- throsis (Fig. 127, A) and non-union (Fig. 127, B) are also frequent occurrences. In the latter event oste- otomy must be performed. In children, in whom the injury is often the result of being run over, the corn- Fig. 129. — Supramalleolar fracture combined with infraction of fibula in a woman seventy years of age, showing moderate displacement. Function perfect (four weeks after the injury). pound variety is prevalent. Still, the most unfavorable cases have an astonishing tendency to heal under care- ful observation of aseptic principles. (See p. 52.) Simultaneous fractures of the loiver end of the tibia and fibula are either supramalleolar or malleolar. (a) Supramalleolar fracture (Figs. 128, 129, and 14 2IO FRACTURES OF SPECIAL REGIONS. 130) of the bones of the leg is produced by direct as well as by indirect violence, the lines of fracture running into the ankle-joint in the majority of cases. This type is analogous to the supracondylar fracture of the femur and humerus, and is generally of a severe character. Fig. 130. — Supramalleolar fracture in a man forty-two years of age, showing considerable displacement. The interosseous space is filled up with displaced fragments, which cause great functional disturbance (four months after the injury). The signs are very well marked, displacement being the most prominent one. The treatment consists in reposition and immobiliza- tion by wire splints, molded after the shape of the foot and leg, or by a well-padded plaster-of- Paris splint. PELVIS AND LOWER EXTREMITY. 21 I Reposition is much more difficult then than that of the well-known simple malleolar fracture. Anesthesia can but rarely be dispensed with. If a plaster-of-Paris dressing is applied, thorough revision must be per- formed at least once a week. Massage treatment should be commenced after two weeks. Restoration to perfect functional ability may not take place for a year. If the interosseous space is free, no functional disturbances may be present even in cases of deformed Fig. I31. — Malleolar fracture. — (After Hoffa). union. (Fig. 129.) But if the interosseous space is filled up with displaced fragments and abundant callus (Fig. 130), osteotomy will be indicated. (b) Malleolar fracture, usually called Pott's fracture (Fig. 131), is generally caused by the body being bent down and outward while the foot is kept fixed. This type is analogous to the fracture of the lower end of the radius, the strong ligamentum carpi volare profundum of which never breaks. The ligamentous 212 FRACTURES OF SPECIAL REGIONS. connection of the tibia with the fibula is so strong that its fracture is generally followed by the break of its fellow. In the corresponding typical fracture of the radius the ulna does not always follow the ex- ample of its fellow, but, as emphasized in the section Fig. 132. — Malleolar fracture in a woman thirty -six years of age, showing a long oblique splinter separated from the external malleolus and a small fragment detached from the internal malleolus (ten days after the injury). on Radial Fracture (p. 153), in many instances it be- comes infracted. Among the signs the most prominent one is a very well-marked displacement, the direction of which is generally sidewise. It should be borne in mind that if the fracture extends over only a small portion of the malleoli, the function of the leg may be so little dis- PELVIS AND LOWER EXTREMITY. 213 turbed that the patient is able to walk considerable distances ; and if the examination be not thorough, contusion or distortion may be erroneously diagnos- ticated — as, for instance, in the case illustrated by figure 132. (Also compare remarks on Fracture of the External Malleolus, p. 224.) The extravasation beino- sometimes considerable, it can be understood that in many instances but little displacement is shown. In such cases palpation always reveals the presence of the fracture. Crepitus is also seldom absent. Taking into consideration its close relation to the ankle-joint, it is easily understood that this injury represents a severe fracture type. In fact, there is a great tendency to deformity as well as to the development of a severe form of arthritis. It has been the author's experience that, especially in childhood, inflammatory processes of the ankle-joint were not infrequently mistaken for old malleolar frac- tures. This may appear strange at first sight ; but in view of the fact that tuberculosis in this region often develops after slight injuries, it is not unnatural that the swelling caused by the tubercular process should be mistaken for a deformity following fracture. In osteomyelitis a preceding subcutaneous trauma is also often reported. The intense pain, the edema, the fever, and the general debility, as a rule, so significant for osteomyelitis, may be sometimes so little marked that differentiation becomes difficult. Figure 142 illustrates this possibility. In this case an anemic girl, eleven years of age, sustained an apparently slight in- jury by falling on the street. There was moderate pain and slight swelling around the ankle-joint, which was regarded as a sprain until the swelling gradually 2 14 FRACTURES OF SPECIAL REGIONS. extended. It was then assumed that there had been a fracture, the displaced fragments of which had caused the swelling, the deformity, and the disturbance of function. A skiagram, taken five weeks after the injury, revealed the presence of an osteomyelitic focus at the lower end of the tibia, and no signs of a pre- ceding injury to the bone. The swelling not permit- ting thorough palpation of the malleoli, the error ap- pears very pardonable. (As to etiology and differenti- ation, compare case illustrated by Fig. 37 '.) The focus was exposed under the guidance of the skiagram and was extirpated. The ease and the secu- rity with which these operative procedures can be carried out under the control of the rays should be emphasized. Formerly it was deemed advisable to chisel up the bone in its whole length in order to be sure that every possible focus was really reached. Now the skiagram dictates even the length of the inci- sion necessary for a thorough removal. The dislocations in the ankle-joint, which are usually either backward or forward, show such characteristic signs that differentiation should not meet with any difficulty. The rare type of subastragalar dislocation, however, which is either inward or outward, may be confounded with a fracture, as long as the Rontgen rays are not consulted. The treatment consists in exact reposition, which is effected while adduction is exercised, the fibula being forcibly pressed against the tibia. To accomplish this well, anesthesia is required in the majority of cases. Immobilization is kept up by a plaster-of-Paris dress- ing, which is applied while the foot is adducted to the rectangular position ; that is, in a direction such as the PELVIS AND LOWER EXTREMITY. 21 planta pedis would normally assume in walking. Whenever the plaster-of-Paris dressing can not be used, the Volkmann splint or the removable plaster- of-Paris splint is to be employed. Massage treatment should be started two weeks after the injury. When- ever there is such doubt as to the significance of the Fig. 133. — Isolated frac- ture of tibia at its upper end in a girl three years of age (three weeks after the injury). Fig. i^_ — Fracture of the shaft of the tibia in a woman twenty-five years of age, sustained at the age of five, after an operation for necrosis of the tibia. injury of the malleolar region that the question can not be settled instantly by a Rontgen apparatus, the case should be treated as one of severe fracture. Union is generally perfect in four weeks. Stiffness of the ankle-joint and swelling of the soft tissues continue often after perfect consolidation. If appo- sition was correct, these conditions will yield to forci- ble motion of the joint, local baths, and massage. In 2l6 FRACTURES OF SPECIAL REGIONS. the case of union in a perverse position, which is a frequent result, osteotomy is always indicated. Isolated Fracture of the Tibia. — Isolated frac- Fig- 135- — Same case as figure 134, showing enormous development of the greatly deflected fibula and the arrest of growth in the tibia. A new movable joint, containing normal synovial fluid and showing well-developed synovial mem- branes, had formed. ture of the tibia may take place at its upper or lower end, or it may take place through the shaft. (a) Isolated fracture through the upper end of the tibia is caused by direct as well as by indirect violence. PELVIS AND LOWER EXTREMITY. 217 Injuries of this kind are rare. (Fig. 133.) They are produced by compression. This fracture may be due to gunshot or to a vertical fall on the foot (fall from a bicycle) — other injuries generally producing simultaneous fracture of the fibula. If the line of fracture is transverse, there is little displacement, the fibula acting as a kind of a side-splint to retain the Fig. 136. — Comminuted fracture of the tibia caused by gunshot from fifty yards' distance (skiagraphed one hour after the injury). fragments in apposition ; but there is local pain, ec- chymosis, and a more or less marked irregularity on the anterior tibial surface. If the line of fracture is oblique, there is more or less lateral deflection. Without the aid of the Rontgen rays, however, an exact diagnosis is often impossible. In fracture of the tibia due to necrosis the growth of the bone may be arrested, as shown in figures 134 218 FRACTURES OF SPECIAL REGIONS. and 135, where the fibula had practically assumed the function of the tibia. The treatment, if there is any displacement, consists in reposition. Otherwise the treatment is identical Fig- 137- — Indications of oblique fracture of the left tibia failing to be repre- sented by the Rontgen rays in the dorsal position. with that for the simultaneous fracture of the tibia and fibula. (b) Isolated fracture of the tibia through its shaft at about its middle may be due to direct as well as to indirect violence, such as a kick, a knock, a fall, or a PELVIS AND LOWER EXTREMITY. 219 gunshot. (Fig. 136.) In children infraction of the shaft is often the result of a moderate degree of violence. (Fig. 138.) The fracture line is sometimes transverse ; in the majority of cases it is oblique, and if there be but little displacement, the diagnosis of the fracture may Fig. 138. — Infraction of tibia in a boy four years of age (three hours after injury). be difficult without the aid of the Rontgen rays. (Compare the history of the case illustrated by Fig. 139, a and &, and described in the section on Errors in Skiagraphy.) The treatment is the same as that for isolated frac- ture through the upper end of the tibia. (c) Isolated fracture of the lower end of the tibia 220 FRACTURES OF SPECIAL REGIONS. (isolated supramalleolar fracture) has the same etiol- ogy as the simultaneous fracture type described pre- viously, with the exception that the force producing it is usually less violent. In childhood infraction is observed sometimes as illustrated by figure 138. The signs are not always well marked. There being A. B. Fig. 139 — Fracture of the tibia. Same case as figure 137. A. Oblique type, in a boy four years of age (twelve hours after the injury). B. Union nearly perfect (four weeks after the injury). no deflection present, they are limited to one unre- liable symptom only : namely, the local pain and ten- derness, which could just as well be due to a simple fissure or a distortion. (Fig. 140.) The Rontgen rays, of course, will never fail to elucidate the true character of the injury. The treatment falls under the same consideration PELVIS AND LOWER EXTREMITY. 221 as pertains to the simultaneous fracture type. (Page 206.) Fig. 140. — Spiral fracture of the lower third of the tibia in a boy of three years (twenty-four hours after the injury). (Note relations of the cartilaginous epiphyses in the knee-joint.) As long as any doubt as to the character of the injury exists, it should be treated as a fracture. If 222 FRACTURES OF SPECIAL REGIONS. reposition has been imperfect, shortening' of the leg and considerable thickening of the ankle-joint may result. Atrophy of the muscles of the leg, varus- or valgus-position, etc., may prevent the patient from walking normally. If, in case of considerable dis- Fig. 141. — Fracture of the lower end of the tibia in a man fifty-two years of age, showing considerable backward displacement. Great functional disturbance (one year after the injury). placement, reposition has been omitted, the tibial fragments may be shifted away from their natural relations, particularly in the articulations between tibia and fibula. This condition is illustrated by figure 141, which shows protrusion of the lower tibial frag- ment to an enormous extent. PELVIS AND LOWER EXTREMITY. 223 It goes without saying that in such an event the function of the ankle-joint is greatly impaired. When consolidation is not perfect (three to five weeks after the injury), there is a chance for redressing the pro- truding fragment under anesthesia, but later on the only remedy possible is offered by osteotomy. Epiphyseal separation of the lower end is some- Fig. 142. — Osteomyelitic focus in the lower end of the tibia, characterized by the translucency of the diseased area. times caused by traction during labor. In connec- tion with fracture of the fibula, compound separation takes place sometimes in older children. The treat- ment is the same as that for isolated fibular fracture. Isolated Fracture of the Fibula (Fig. 143, A and B). — The isolated fracture of the fibula generally occurs at the lower third. 224 FRACTURES OF SPECIAL REGIONS. The signs as well as the treatment fall under the same considerations as those of the malleolar fracture. The fibula may also fracture at any other point, but such occurrence is extremely rare. The signs of the A. B. Fig. 143. — A. Isolated fracture of the fibula in a man twenty-nine years of age (one day after the injury). B. Isolated fracture of the fibula, causing moder- ate functional disturbance, in a man forty-two years of age (three weeks after the injury). latter type are but little marked, the only important one being represented by local pain. The cause of the fracture of the fibula at its lower end, which is also called fracture of the external mal- leolus, is the same as that of distortion. The outer margin of the astragalus pressing against the external malleolus, while the foot is bent in forced supination, it PELVIS AND LOWER EXTREMITY. 225 is natural that the malleolus yields above the margin of the astragalus, since the very strong calcaneofibular ligament generally resists the force. The comparison with the mechanism of the fracture of the lower end of the radius is also obvious. Some patients are able, after having sustained a fracture of the external malleolus, to walk, and even to work, so that the erroneous diagnosis — distortion — is often made. The author is convinced that he has committed this error himself before he had a chance to avail himself of the advantages of the Rontgen rays. If such cases are consequently treated as distortions by the application of ointments, fomentations, etc., enormous callus formation of the external malleolus and varus-position may be the result. Naturally, the relation of the external malleolus to the astragalus is influenced by the faulty position. The external margin of the foot exclusively being utilized while walking, it is natural that the metatarsal bones are also shifted sideward, and finally even the knee will participate in the faulty position. The treatment consists in simple immobilization (plaster-of-Paris). The tibia acting as a side splint, union becomes perfect under almost any immobilizing treatment. The rule that osteotomy must be resorted to in case the function of the extremity is disturbed applies to all the various types of fractures of the leg in which union has taken place in a faulty position, provided the proper time for bloodless redressement has elapsed. The modus operandi is practically the same as that described for osteotomy of the femur — that is, chisel- 15 2 26 FRACTURES OF SPECIAL REGIONS. ing off of protruding or intervening fragments, or severing the displaced fragments entirely by means of a chisel or the Gigli wire saw. (Compare p. 189.) Pseudarthrosis requires osteotomy much more fre- quently, especially in children, in whom the fractured ends have a tendency to become thin and atrophic, thus reducing the extent of their surface, which is a most unfavorable item in the question of agglutination. Such patients are unable to work without an immo- bilizing apparatus or a prosthesis. Wherever the sur- faces are too small for perfect approximation, the bone-fragments should be freshened laterally and united by strong silver wire. (See Fig. 13 c.) It is of the greatest importance that no periosteum should be sacrificed during the operation. In the event of extensive loss of substance of the tibia, the upper tibial fragment may be united with the lower portion of the fibula after the latter has been trimmed proportionally. FOOT. Fracture of the foot concerns either the tarsal or the metatarsal bones or the phalanges. Fractures of the tarsal bones are always caused by direct violence (passing of a carriage-wheel (Fig. 144), falling of a heavy weight upon the tarsus). There is often extensive destruction of the soft tissues present at the same time. The astragalus and calca- neum are the tarsal bones most frequently involved in these fractures. Fracture of the astragalus (Fig. 145) is generally caused by a fall, its neck representing the seat of pre- PELVIS AND LOWER EXTREMITY 227 Fig. 144. — Fracture of tarsal bones, caused by a heavy truck, followed by gangrene of foot, in a boy four years of age. Line of demarcation above the malleoli ecchvmotic, but healthy integument appearing prominent above the gan- grenous area; skin peeling off from the gangrenous dorsum, (ten days after the injury) . Fig. 145. — Compression fracture of astragalus in a twenty-eight-year old laborer who was run over (four weeks after the injury). 22; FRACTURES OF SPECIAL REGIONS. dilection. It is often associated with other severe injuries of the ankle-joint. The atragalus is a peculiar bone inasmuch as it articulates with four different bones and shows no point of insertion for any tendon. Its fracture may concern the body as well as the neck of the capitulum. The signs consist in the presence of local pain and tenderness, crepitus, and loss of function. In the rare event of displacement the possibility of dislocation may be thought of. The considerations would be then Fig. 146. — Fracture of the calcaneum. that the malleoli appear to be intact, that there is considerable shortening of the extremity, and that the characteristic contours of the astragalus can be well palpated. Fracture of the astragalus often remains unrecognized and is treated for malleolar fracture or distortion of the ankle-joint. The Rontgen rays, of course, will always disclose the true condition. The treatment consists in reposition in case of dis- placement, and this is possible sometimes only after division of the tendo Achillis. If there be but little PELVIS AND LOWER EXTREMITY 229 swelling, immobilization is accomplished by a plaster- of-Paris dressing. Otherwise, especially in the event of synovitis, wire splints in connection with the appli- cation of Burow's solution are indicated. (See p. 67.) Fig. 147. — Non-reduced fracture of the calcaneum, showing considerable sideward displacement, thus resembling dislocation, in a man thirty-eight years of age. Enormous swelling (two weeks after the injury). Fracture of the calcaneum (Fig. 146) is caused either by direct violence (fall from a high point, passing of a cart- or carriage-wheel) or by indirect violence (sudden contraction of the tendo Achillis). It predominates in 230 FRACTURES OF SPECIAL REGIONS. masons, roofers, miners, and workmen on elevated railroads. It concerns either the body or the processes of the bone. The signs consist in ecchymosis, local pain, displace- ment, crepitus, and loss of function. The arch of the foot sinks down and the foot appears flat. Some- times the swelling following the injury is so consider- Fig. 148. — Oblique fracture of first metatarsus in a rachitic girl of twelve years healed without deformity (five weeks after the injury). able as to prevent exact palpation ; and as a conse- quence distortion or malleolar fracture may be errone- ously supposed to exist. The prognosis as to function is always doubtful. The treatment consists in reposition and immobiliza- tion. The first requirement sometimes can not be PELVIS AND LOWER EXTREMITY. 23 1 fulfilled, apposition of the fragments being possible only by bone suture or ivory pegs. Ordinarily, the displacement can be overcome by resting the leg upon a double inclined plane. In case of excessive callus formation resection of the exuberant masses is indicated. If either the calcaneum or astragalus is crushed, amputation should be performed without delay. Fractures of the scaphoid, cuneiform, and cuboid bones fall under the same considerations as those of the metatarsal bones. In all these fractures the arch of the foot sinks down, causing talipes-position. Fractures of the metatarsal bones (Fig. 148) and the phalanges are always produced by direct violence (falling of a heavy weight, passing of a wagon-wheel, the latter being an especially frequent cause in chil- dren). Such fractures are either isolated or simultane- ous, sometimes all the bones being fractured at the same time. Usually these injuries are associated with lesions of the soft tissues. Their superficial location makes recognition of the character of these injuries easy, as a rule. Fracture of a metatarsal bone, especially the second or third, is frequently observed in the army, as a con- sequence of overburdening the marching soldier. In the pre-R6ntgenian era this much dreaded condition, known as "foot edema," was regarded as dependent upon a pathologic change in the soft tissues. The treatment consists in immobilization by a small plaster-of-Paris dressing after reposition is done. Union generally becomes perfect in three weeks. In compound fractures the wire splint should be used in connection with antiseptic lotions. (See p. 67.) 232 FRACTURES OF SPECIAL REGIONS. Later on, the fenestrated plaster-of-Paris dressing is to be employed. (Fig. 5.) If the bones are crushed, amputation should not be delayed. FRACTURES OF THE BONES OF THE TRUNK. Fractures of the bones of the trunk are divided into those of the thoracic wall (ribs and sternum) and those of the spinal column (body, arch, and the spinous and transverse processes). FRACTURE OF THE RIB. Fractures of the ribs (Fig. 149), while rare in chil- dren, are frequent in adults, and represent fifteen per cent, of all fractures. The injury may be caused by direct as well as by indirect violence. In the first event (blow against the thoracic wall, fall at the margin of the sidewalk, staircase, table, etc.) the fragments are generally driven inward. (Fig. 150.) If caused by a gunshot, the rib is splintered, the intrathoracic organs being generally also involved. A simple transverse fracture may be produced by a bullet fired from so great a distance that its force is considerably diminished when it strikes the rib. If the fracture is caused by indirect violence (as, for instance, by compression of the thorax), it is often associated with fracture or contusion of the humerus. In rare instances the fracture is produced by muscular contraction, in which event the fragments are generally driven outward. According to the age of the patient or to the degree of violence, an infraction (Fig. 149) or a true fracture (Fig. 150) may result. Infractions are much more frequent than fractures. In children the thorax is so elastic that fracture is caused only by a considerable decree G f violence. The signs consist in intense local pain and in the crepitus that results if the fragment is pressed down- ward by the palm of the hand. Manual pressure also increases the painful sensation during the act of in- spiration. Deep inspiration and stooping toward the opposite side invariably cause great pain. If the rib Fig. 149. — Infraction of ribs (no displacement). is fractured only, displacement generally does not take place, but if several ribs are broken, as shown by figure 150, considerable displacement may result. It is in these cases that the intercostal artery may become injured, so that an aneurysm may develop. Fractures in the vicinity of the vertebrae impair the function of the articulatio costotransversalis and costovertebralis. In case the lungs are injured, hemoptysis is always, and hemothorax, pneumothorax, and emphysema are sometimes, present. The last-named condition may 234 FRACTURES OF SPECIAL REGIONS. extend to the neck and abdomen, and in severe cases it may involve the whole body, the air escaping from the lung' into the surrounding connective tissue. The left fourth, fifth, and sixth ribs at their sternal junctions endanger the pericardium and vagus, while the ante- rior splinter-fractures of the sixth rib may injure the Fig. 150. — Fracture of ribs about their angles, causing kyphosis, in a woman of fifty years. On the left, the fourth rib shows slight, the fifth considerable, dis- placement. On the right, the fragments of the fifth rib overlap, while the sixth rib sh6\vs moderate displacement. pleural sinus. The right seventh, eighth, and ninth ribs may cause laceration of the liver tissue. The treatment should be mainly directed to immo- bilization. Taking into account the relation of the ribs to the pleura and lung, it is evident that immobili- FRACTURES OF THE BONES OF THE TRUNK. 235 zation should not be expended upon the thoracic wall alone, but must also affect the intrathoracic organs. The first requisite will be attained by the fixation of the fragments, which is accomplished by a large and broad strip of rubber adhesive plaster or a large piece of moss-board (see Fig. 23) applied during ex- piration. The second and more important requisite, immobilization of the lungs, — in other words, reduc- tion and diminution of the respiratory movements, — is fulfilled by a liberal administration of opiates. Pleuritis sicca, one of the most frequent results of simple infraction as well as of true fracture of a rib, is treated after general principles (rest in bed, fomen- tations, opiates, etc.). The same views apply in the much rarer event of pneumonia, which, as a rule, is of moderate extent and significance. Sometimes tuberculosis develops after an injury of the pleura or the lungs. Hemothorax or pneumothorax, if present to a mod- erate extent, demands aspiration, under the most thorough aseptic precautions. (Compare p. 198.) In most cases, however, it is more rational to expose the pleural sac by the resection of three or more ribs. The same holds good in pyothorax. As to the technic, compare author's description.* Pericarditis is not infrequently observed after rib- fracture. If a splinter-fragment has pierced the peri- cardium, injury to the heart may also result. The true character of the trauma can always be elicited by the Rontgen rays. If, for instance, the clinical symptoms are slight, and the rays show no displaced splinters in the direction of the pericardium, medical treatment *** International Med. Magazine," January, 1897. 236 FRACTURES OF SPECIAL REGIONS. alone is in order. Even if a bullet, after having frac- tured a rib, has entered the pericardium, there may be no need of surgical interference, no severe symptoms being present. An autopsy made by the author on a patient who was shot through the thorax eight years Fig. 151. — Compound fracture, showing displacement of fifth, sixth, and seventh ribs, in a boy ten years of age (four weeks after the injury). before his death revealed a bullet embedded in fibrous tissue in the pericardial sac, where it had never caused any disturbance. But the evidence of a sharp bone-splinter pointing toward the pericardium indicates the urgent necessity of exposing the pericardial sac after the resection of FRACTURES OF THE BONES OF THE TRUNK. 237 the left fourth, fifth, and sixth ribs. They do not necessarily need to be resected in their totality, but may be folded up at their sternal junctions like a bone-flap of the skull. (Fig. 158.) It goes without saying that in such cases the clinical symptoms are severe according to the anatomic con- dition. The signs of an injury to the heart are severe shock (fainting, cyanosis, weak pulse), pulsation in the wound, hemopericardium, and the murmur. If the fourth and fifth ribs are dissected at the mammillary line and folded up at the sternum, the anterior surface of the right and a portion of the left ventricle are exposed. The pericardium must be severed from the pleura. Any wound in the heart must be united with silk (medium size). The left ventricle is best sewed during systole, and the right during diastole. In compound fractures of a rib (Fig. 151) the pack- ing of the wound with iodoform gauze is indicated. If there be much hemorrhage, the packing must be done tightly and extensively, in the form of a tampon bag.* If the extent of emphysema is moderate, no inter- ference is required ; but if it be extensive, multiple incisions are indicated. To sum up, it can readily be seen that the prog- nosis of fracture of the ribs depends entirely upon the degree of participation of the intrathoracic organs. In simple cases union is perfected in from three to four weeks. Fractures of the costal cartilages occur gener- ally at their junction with the ribs, sometimes also in * Compare author's " Manual on Surgical Asepsis," W. B. Saunders, Phila., p. 209. 233 FRACTURES OF SPECIAL REGIONS. their continuity. The consideration of the etiology, signs, and treatment of this condition is identical with that of fracture of the ribs. It must be considered that in aged people the cartilages become ossified. FRACTURE OF THE STERNUM. Fracture of the sternum (Fig. 152) is rare (less than one per cent, of all fractures). It is generally caused Fig. 152. — Fracture of the sternui by direct violence (heavy weight falling upon the chest, gunshot wound, etc.). The line of fracture is nearly always transverse. It is but exceptional that it is caused by indirect violence (muscular contraction, sudden bending of the trunk, the chin being pressed against the sternum). If caused by a gunshot wound, the seat of the frac- FRACTURES OF THE BONES OF THE TRUNK. 239 ture may be at any portion of the sternum. Other- wise it is generally at the junction of the manubrium with the corpus. The signs are local circumscribed pain, more or less displacement and crepitus, cough, and sometimes hemoptysis and dyspnea. The prognosis is favorable except in cases in which there is injury done to the mediastinum. The treatment consists in reposition of the frag- ments. This is accomplished by putting the patient into a reclined position by placing a large pillow under him, so that the receding fragment protrudes. The head should be bent far backward at the same time. If this procedure does not prove to be efficient, ex- tension with Glisson's cradle is advisable. FRACTURE OF THE SPINAL COLUMN. Fractures of the spinal column (Figs. 153, 154) are rare (less than one per cent.), and are subdivided into fractures of the vertebral body, the arch, and the spinous and transverse processes. Fracture of the vertebral bodies occurs gener- ally in the dorsal and lumbar portions. The place of predilection is between the twelfth dorsal and the first lumbar, and at the fifth or sixth cervical vertebra. It is generally caused by indirect violence (heavy weight falling upon head or shoulder, fall from horse or bicycle). Direct violence produces it but exception- ally. The direction of the fracture-line may be either oblique, transverse, or longitudinal. The first variety is the most frequent, the last-named the rarest. 240 FRACTURES OF SPECIAL REGIONS. Infractions or fissures are also observed, but they are seldom diagnosticated on the living patient. Sometimes more than one vertebra is concerned. The most important sign is the traumatic kyphosis, produced by displacement of the spinous processes, whereby a prominence is caused. Naturally, there is always circumscribed pain. Crepitus and abnormal mobility are generally absent. In case of a crushing of the bone the spinal cord Fig. 153- — Position of trunk in fracture of the spinal column. hardly ever escapes injury, the latter generally being of the nature of a severe contusion. Lighter injuries, such as commotion or compression, are of exceptional occurrence. In the event of medullary contusion there are well- marked signs of motor and sensory disturbance: viz., paralysis of both legs, of rectum and bladder, local anesthesia of the anal and perineal regions, and some- times priapism. In severe cases dyspnea and high FRACTURES OF THE BONES OF THE TRUNK. 24 1 temperature may complete the symptom-group of this grave condition. While in commotion and compression (caused in some instances by a blood extravasation) there is only slight paresis, which disappears in a few days, in con- tusion the paralytic symptoms remain unchanged. Spinal myelitis develops, with an ascending tendency, the paralysis progressing in the centripetal direction. The paretic bladder breeds cystitis and pyeloneph- ritis, and the anesthesia of the paralyzed portions tends to decubitus on the prominent bone-portions of the pelvis and the lower extremities, so that there are present all the conditions for the development of pyemia. The higher up the fracture takes place, the less favor- able is the prognosis. Importance should be attached also to the proximity of the injury to the vital organs. If in fracture of the first and second cervical verte- brae the spine is compressed on account of much dis- placement, death is almost instantaneous. If the de- gree of displacement is very slight, the patient may live for a short while. In view of the fact that the brachial plexus is com- posed of the fifth, sixth, seventh, and eighth cervical nerves, as well as of the first dorsal nerve, it will be understood why paralysis of the upper extremities as well as of the abdominal and intercostal muscles is present in fracture above the third dorsal vertebra ; also why the character of the respiration is distinctly diaphragmatic, and why it is the diaphragm only, be- sides a few cervical muscles, that keeps up the respi- ratory function. If the phrenic nerve, which branches off between 16 242 FRACTURES OF SPECIAL REGIONS. the third and fourth cervical vertebrae, is compressed in this region, its paralysis will be the consequence, and death will follow almost instantly. Fig. 154. — Fracture of dorsal vertebra, causing displacement and contusion. In fracture between the third dorsal and the third lumbar vertebra the spine is injured below the FRACTURES OF THE BONES OF THE TRUNK. 243 brachial plexus. Consequently, the function of the arm remains intact, while the functions of the bladder, the rectum, and the lower extremity are suspended, first retention, and later on incontinence, of urine and feces setting in. If the line of fracture is situated higher up, the abdominal muscles may also become paralyzed. Then tympanites will be produced, which pushes the dia- phragm upward so that respiration is greatly inter- fered with. Some of the intercostal muscles may also be paralyzed, so that the respiratory difficulty is so much more increased. There may also be the chain of symptoms of irrita- tion, such as hyperesthesia, neuralgia, and spasms. The reflexes are increased if the compression is con- siderable, while they may be unaltered if it is slight. The vasomotor sphere may react by an enormous elevation of temperature if the lower cervical region is involved. Continuous erection and frequent ejacula- tions of sperma may also persist for days. The treatment consists in reposition of the fragments. Sometimes this can be accomplished by manual force applied after the induction of profound anesthesia. This can especially be done in the lower dorsal and in the lumbar portions. The fragments are drawn apart by placing the patient in Glisson's cradle, counterextension being accomplished by elevating the bed. Later on, a plaster-of-Paris corset is applied while forcible weight-extension is kept up. If reposition is impracticable, distraction or the forcible separation of the fragments must be re- sorted to. In the treatment great stress has to be laid on very 244 FRACTURES OF SPECIAL REGIONS. careful control and nursing. Frequent change of posi- tion, while necessary, must be done under great pre- cautions, as it must be remembered that even a light torsion of the injured spine may cause instant death. The patient rests best on a water-pillow or, preferably, on a water-bed. Decubitus must be prevented by exercising the most minute cleanliness and by placing the patient upon rubber water-bags. Frequent change of position is also required. Decomposition of the urine must be counteracted by frequent catheterization, followed by irrigation with a weak solution of bichlorid of mercury (i : 25,000) and injection of a five per cent, emulsion of iodoform in glycerin. With the aid of the Rontgen rays the type of the fracture and the size and number of the splinters and their location can be so well represented that the indications for the mode of treatment are set forth clearly. If there is only slight angular displacement, reduction can nearly always be accomplished. But in the event of intraspinal hemorrhage and when bone- fragments, driven into the canal, press upon the cord, operative interference is required. Under the application of the Rontgen rays the re- sults of operation, which formerly had been confined to exploration, became much more encouraging. The field of operation being outlined by the skiagraph, the modus operandi could be determined before operation. While at one time it was deemed advis- able to expose a large portion of the spinal column in order to ascertain that every possible injury had really been reached, now all the operative procedures can FRACTURES OF THE BONES OF THE TRUNK. 245 be carried out under the indication of the rays with ease and security, even the length of the incision necessary for the removal of bone-splinters being shown by the skiagraph. It is surprising that surgeons who find it most nat- ural to relieve by immediate operation bone-pressure caused by a depressed fracture of the skull should hesitate to perform the similar operations upon the spinal column. Nothing, indeed, is more natural than reduction or removal of a fragment pressing upon the spinal cord. Blood-clots can then be evacuated from the cord ; and its membranes, and even wounds of the nerve-tissue, may be united. It is hardly necessary to add that such procedures must be carried out under the most stringent aseptic precautions. (Compare p. 52.) The best method of exposing the spinal canal (tre- phining of the spinal canal, or laminectomy) is by the formation of a lateral flap. This is done by making an incision about seven inches long over the arches down to the periosteum and by reflecting the soft tis- sues to the bases of the spinous processes, which are then divided with cutting bone-forceps. The processes may be lifted up in the flap, like a bone-flap in the skull. (Fig. 160.) The dissection is continued to the other side until the exposure of the fractured area is complete. Now the depressed bone may be lifted or removed, a hematoma may be evacuated, and lacer- ated nerves may be united. If the bone-flap is rein- serted now, union by first intention can be expected, the remaining bone-gap being filled up with thick fibrous tissue. 246 FRACTURES OF SPECIAL REGIONS. But if suppuration is present, the principles of open wound treatment should be kept up.* In case of excessive callus, pressing upon the cord, or of faulty union, laminectomy is also indicated, even at a late period. Sometimes in such cases occlusion of the spinal canal, caused by adhesions of the mem- branes, is observed. It goes without saying that they must be thoroughly freed. In view of the soft, spongy consistence of the verte- bral bodies, it is evident that long-continued immo- bilization — at least three months — is necessary for thorough consolidation. If the patient is allowed to get up too early, compression will be increased by the weight of the body, and kyphosis will be a natural consequence. In severe cases the treatment may be continued for a whole year. Massage treatment should be com- menced after three months ; later on, faradization is in order. Fractures of the arch are rare, and occur more frequently in the lower than in the upper portion of the vertebral column. They are caused by indirect violence (fall or blow on the long spinous process) the effect of which is transferred to the arch. Among the signs the predominant one is the down- ward displacement of the spinous process of the ver- tebra involved. Otherwise the signs as well as the treatment of this type require much the same consid- eration as those of the fracture of the vertebral body. Fracture of the spinous and transverse pro- cesses is extremely rare. * Compare author's essay on "Laminectomy," " American Medico- Surgical Bulletin," Feb. i, 1894. FRACTURES OF THE SKULL. 247 Fractures of the spinous processes are caused by direct violence (blow or fall), and prevail at the lower dorsal and the lumbar portions of the vertebral column. The signs are well marked, the predominant one being abnormal mobility of the fragment. Fractures of the transverse processes are still rarer, and their recognition is extremely difficult on account of the thick muscular layer protecting them. The treatment of this fracture type is very simple. Patients should assume the dorsal decubitus for two weeks, and are then provided with a plaster-of-Paris corset for another few weeks. A good skiagraph will show a fissure as well as an infraction at any part of the spinal column. In repro- ducing it in print, however, much of the delicacy of the representation becomes lost, and for that reason the author has preferred not to offer any of his skiagraphic illustrations of this fracture type. FRACTURES OF THE SKULL. Fractures of the skull are comparatively rare (1.3 per cent, of all fractures). They deserve special con- sideration for the reason that their course can seldom be foretold with certainty, extensive penetrating inju- ries sometimes healing with little reaction and no ill consequence, while comparatively small lesions of ap- parent insignificance are liable to be followed by fatal meningitis. They concern the vertex or the base of the skull or the bones of the face. Fractures of the skull are uncommon in children on account of the thin and elastic structure of the bones, 248 FRACTURES OF SPECIAL REGIONS. which makes them yield to direct violence. This ex- plains why fissures and fractures of the tabula vitrea are so extremely uncommon in childhood. The bones being united by soft sutures and the dura mater being firmly adherent to the infantile cranium, it follows that an injury of the skull will be, with few exceptions, combined with a laceration of the intracranial tissues ; at least, of the dura mater. Sometimes the arteria meningea media is found ruptured. Such cases re- quire very careful observation and judgment, since the early symptoms of meningitis or encephalitis may be veiled. The treatment consists mainly in rigid asepsis. In hernia cerebri caused by compound fracture of the skull transplantation of bone-tissue is indicated. In fracture of the skull in older children, in whom the bones are consolidated, the conditions are the same as in adults. FRACTURES OF THE VERTEX represent the great majority of fractures of the skull, and are nearly always caused by direct violence (fall or blow on the head, weapon, gunshot). Indirect violence, the force inflicted radiating, causes it but rarely. (An illustration of the insignificance of indi- rect violence is afforded by the case of President Lin- coln, in which the bullet, after having pierced the left side of the occiput, went to the cranial base below the right anterior lobe. The autopsy revealed a fracture in the roof of the right orbit, which had not been touched by the bullet.) There may be a simple fissure in the skull, as well as comminuted and compound fractures. FRACTURES OF THE SKULL. 249 A remarkable feature of fractures of the vertex is the much greater extent of the fracture in the internal Fig- 155- — Schematic representation of dissemination of force. F'g- 156. — Protrusion at the inner table, caused by a blow from a hammer. table than in the external. This is caused by the force bending the portion involved inward. Thus the outer 250 FRACTURES OF SPECIAL REGIONS. convexity and the concavity of the inner surface are replaced by a flatness of that portion, the external table being compressed and the internal table being overstretched. (Fig. 155.) The extent of the frac- ture naturally is greater in the inner table. When a stick is broken, the separation of the fragments commences at the overstretched side, or convexity, Fig. 157. — Fracture by gunshot, comminuted type. not on the compressed concavity. In like manner the greatest extent of fracture in injuries of the vertex is shown upon the concave side. There are isolated fractures of the external table as well as of the internal. The latter injury occurs some- times when a force, applied from without, is too weak to compress the external table to such an extent as to FRACTURES OF THE SKULL. 251 cause its fracture, but still is powerful enough to stretch the molecules of the inner table to such an ex- tent that a fracture must result. (Fig. 156.) On the other hand, it may happen that a force (gunshot) in- flicted from within is strong enough to fracture the inner, but too weak to permit of its fracturing the outer, table. Fissures may be limited to the external table, and Fig. 158. — Fracture of the orbit caused by a revolver bullet, which, after having perforated the left orbit, was arrested at the right sphenoid process. may represent but a small crack ; or they may show an irregular radiating fracture-line (stellate), the branches of which separate widely. Fractures are generally of the comminuted char- acter, their fragments generally being separated from each other entirely. They may also show an irregular radiating fracture-line (splintered stellate type). The 252 FRACTURES OF SPECIAL REGIONS. inner table is always injured to a greater extent than the outer in such cases. There is often a considerable depression of the splintered area, some of the splinters projecting toward the interior of the skull. Necessarily, the brain must in such cases be more or less injured. If caused by gunshot (Figs. 157 and 158), there may be considerable loss of substance. Usually there is a small round defect at the outer table, comminution at the inner one, and penetration of the splinters into the brain-substance. The signs are local as well as general. The local signs are well marked in open fractures. To ascertain their extent the injured area must be thoroughly exposed. Careful exploration is then made by dilating the wound well and keeping the wound margins far asunder. Closed fractures, if comminuted, are also easily diag- nosticated, especially so if there is depression present ; but fissures, which naturally show no displacement, are recognized with difficulty. Their circumscribed blood extravasation below the periosteum and galea is easily confounded with a hematoma of the galea caused by simple contusion. Local pain also represents an unreliable symptom, so that without the aid of the Rontgen rays a positive diagnosis often can not be made. The general signs are more marked than the local. The function of the brain being exercised by some par- ticular circumscribed portions, it is evident that from the particular kind of functional disturbance the im- pairment of a certain area can be guessed. The expression of these functional disturbances may FRACTURES OF THE SKULL. 253 be either paralytic or spasmodic, or both. Destruction of a certain brain-portion means destruction of function — that is, paralysis ; while slight injury might only mean irritation, which would find its clinical expression in contractions — spasms. In other words, if the paralysis extends over a cer- tain group of muscles (circumscribed paralysis ; mono- plegia), a certain local injury must be suspected. The same statement applies to a combination of paralysis and spasm, while spasms of a certain group of muscles alone (monospasms) point to a lighter injury of the same focus. As in the case of analogous fracture of the spinal column (p. 241), distinction has to be made between commotion, compression, and conttision of the brain. Cerebral commotion consists in the injury of any small brain particles combined with a slight degree of blood extravasation. It is followed by nausea and vomiting, vasomotor paralysis, which finds its expres- sion in the weak and slow pulse (in several cases, as slow as forty a minute), pallor of the face, coldness of the extremities, superficial respiration, and in the sudden loss of consciousness. The latter symptom may be present for only a few minutes, and would then point to a slight degree of commotion only ; but in severer cases unconsciousness may last for two or three days. Then there is also retention of urine, as well as involuntary passage of urine and feces. Among the sequels of this condition diabetes mellitus and dia- betes insipidus are sometimes observed — disturbances of tissue-change which would indicate an injury of the fourth ventricle (Claude Bernard). The most characteristic symptom of cerebral com- 2 54 FRACTURES OF SPECIAL REGIONS. motion is a sudden loss of consciousness, the patient collapsing at the very moment he receives the injury. The clinical picture shows the motionless patient in a soporose condition, the face pale and showing no ex- pression, the staring eyes wide open and the pupils not reacting. If the arm or leg is lifted up, it falls down again without indicating any contraction of the muscles. No irritation of any kind (yelling at the patient or sticking him with a pin) will produce reac- tion. It is only the weak, superficial, and slow res- piration, and the small, slow, and irregular pulse which indicate that life is not yet extinct. In a very slight degree of commotion, such as is often observed in bicycle accidents, there is loss of consciousness for a few minutes only, followed by slight headache and vertigo, ringing in the ears, and a feeling of general weakness, which passes off in a few hours. Cerebral compression is always clue to extravasation from the arteries, especially the meningea media. It increases gradually, and the amount of intracranial blood may become so abundant that an anemic condi- tion of the whole brain is produced. Such blood ex- travasation taking place gradually, it follows that the symptoms of pressure are also manifested by degrees. At first muscular spasms, combined with paralysis of the extremities of the opposite side, are observed, while later on the paralysis becomes general. These symp- toms are then followed by loss of consciousness and considerable slowness of pulse. Contrary to commo- tion, the face appears red, the eyes shine, and the pupils are contracted. The quality of the pulse is full, but it may be below forty a minute at first ; later on, it FRACTURES OF THE SKULL. 255 becomes frequent. Finally, there supervenes an ex- treme slowness of respiration. Among the sequels epilepsy, caused by pressure upon the cortex, may be mentioned. Insanity also develops sometimes. Cerebral contusion is due to the penetration of a bone-splinter or missile into the brain. If the pene- trating force (bullet, stone) goes through the skull, there is generally considerable comminution, which is always followed by marked focal symptoms. Motor aphasia, for instance, points to injury of the left frontal convolution of the left hemisphere. When, in a case of gunshot wound in the temple, hemiplegia is ob- served on the other side, destruction of the motor cen- ters is to be assumed. When modern firearms were introduced, it was predicted that injuries in war would be more humane than they had been. The size of the new bullet being reduced from 0.7 to 0.3 inch, its rate of projection increased from four to six hundred inches a second, and its penetrating force being made about six times greater, it was believed that the thinness and the great force of the bullet would cause a clean, round, canal- like foramen. This was proved to be an error by the experiments of the author made in February, 1896, at Governor's Island, N. Y. As soon as the author had a chance to utilize Rontgen's discovery, he studied the form and degree of destruction produced by the new army rifle (Krag-Jorgensen) in the following manner : Thanks to the courtesy of the officer in charge at Gov- ernor's Island, the author was enabled to skiagraph leg and skull immediately after they were shot at by a soldier of the garrison at various distances. Contrary to all theories, the bones as well as the soft tissues 256 FRACTURES OF SPECIAL REGIONS. showed the most destructive effect. Compare, for in stance, figure 136, which shows the tibia at its lower third transformed into a mass of bone-splinters. If a bullet enters the cranial cavity, the intracranial pressure is immensely increased, an explosive effect taking place. No doubt the lateral transmission of the energy of the bullet, at least in a zone of 350 meters, produces extensive comminution, and while the tribute of ad- miration is due to the genius of the inventor of the new instrument of destruction, humanity itself has no reason for triumph. Paralysis of the hypoglossus or facial nerve implies a contusion of the correlative centers of Rolando's sul- cus, while paralysis of an arm or a leg means an injury of the adjacent centers (central sulcus). The relations of the outer wound itself to the sup- posed intracranial injury have, of course, to be taken into close consideration. If, for instance, there is a paralysis of the facial nerve, destruction of the center of this nerve is to be assumed, provided the situation of the outer wound proves that the nerve itself could not have been injured. In such a case the functional disturbance must necessarily be clue to an intracranial injury. There are, however, puzzling reports of cases in which, in spite of extensive injury to the brain, focal symptoms were absent. The author, for instance, observed a case in which a thin knife was thrust into the left upper eyelid of a man of thirty-two years. The wound was closed in two days. No reaction being observed, the patient attended to his business as usual. Six days later nausea and vertigo, followed FRACTURES OF THE SKULL. 257 by convulsions, set in. When the author saw the patient on the following clay, delirium had supervened. An immediate operation was advised, but before the family would consent to it, the patient died. The autopsy revealed the presence of an abscess at the base of the brain, the blade of the knife having pierced the roof of the orbit. The lower surface of the ante- rior lobe also was pierced by bone-splinters and trans- formed into a pus-focus. In summing up, it is evident that for commotion the sudden loss of consciousness and the small pulse, for compression the gradual loss of consciousness and the full, slow pulse, and for contusion the well-marked focal signs, are most characteristic. Simple fractures, not combined with any cerebral injuries, usually heal within four weeks. In commo- tion perfect recovery generally takes place also. But in compression caused by hemorrhage from the arteria meningea media the result is fatal in the great major- ity of cases. In contusion perfect recovery may also take place, if the extent of the lesion is quite limited ; but in by far the greater majority of cases grave func- tional disturbances remain or an abscess forms. Epi- lepsy, defective memory, and even insanity may de- velop. Epileptiform symptoms may be caused by pres- sure conveyed by protruding bone-tissue in badly wasted fractures. The treatment varies according- to the character of the injury. Simple fractures heal without any treat- ment. In commotion a stimulating therapy, such as is employed in shock, is indicated. The author recommends especially for this purpose the methodic and frequent hypodermic infusions of normal salt 17 258 FRACTURES OF SPECIAL REGIONS. solution. The subcutaneous injection of camphorated oil and atropin is also advisable. Grave cranial injuries require the most rigorous operative interference. In compression temporary re- section, followed by the removal of the blood-clots and ligation of the arteria meningea media, must be per- formed without delay. In open fractures the most Fig. 159. — Transverse fracture of frontal bone, sustained fifteen years ago by a man twenty-five years of age. (Compare Fig. 161.) thorough asepsis (see p. 51, on Compound Fractures) is required. Especial care has to be taken in remov- ing all foreign bodies — as, for instance, bone-splinters ; also hairs that may have been carried along with the foreign body, since they are effective carriers of infec- tion. The dura mater must always be thoroughly exposed. FRACTURES OF THE SKULL. 259 Of course, bone-splinters can be removed only when the external opening- is sufficiently wide. For widening the opening different means may be employed : A chisel and cutting bone-forceps are used for enlarging the fractured area. (See Fig. 164.) When, after thorough exposure, a splinter-fragment or a foreign body is located, it is seized with forceps and carefully extracted. (Fig. 163.) If a fragment is tightly ad- herent to the dura mater, it should never be extracted by force, but must be liberated by incising the dura mater. An impacted fragment is relieved best by Fig. 160. — Formation of fla P- making an additional opening in the immediate vicinity (Fig. 165) in order to introduce a lever there which permits of thorough lifting. Depressed fragments the connection of which with the periosteum is well pre- served are simply lifted with a periosteal elevator. If the bone is intact, or if there is only a fissure, or in case a fracture with little depression is present, or if a small foreign body is to be extracted, the old trepan or an electric saw is to be preferred. The ingenious apparatus advised by Seneca D. Powell (Fig. 162) is especially useful in such cases. In suitable cases the osteoplastic resection of the 2 60 FRACTURES OF SPECIAL REGIONS. skull can be done by forming a bone-Hap. The technic of this operation consists in dissecting the soft tissues down to the periosteum in the form of a Greek Q. (Figs. 1 60, 161.) The edges of the flap will retract some- what. At the margin of the skin-flap the periosteum Fig. 161. — Osteoplastic resection, showing scar produced l>y the injury, and also line of incision for osteoplastic resection in case illustrated by figure 159. is incised and a groove is chiseled into the bone in the same line in which the bone-flap had retracted. The groove can also be formed by Powell's saw. (Fig. 162.) The groove should be made in an oblique direction FRACTURES OF THE SKULL 26l so that the outer table rests on the inner when it is returned again into place. If an elevatorium is introduced underneath the bone-flap, the latter can be raised and infracted, so that the whole flap may be turned back, the soft tissues serv- ing- as a hinge. In all operations in the skull the incisions should be made longitudinally whenever possible, according to the direction of the arterial branches. If a transverse Fig. 162. — S. D. Powell electric saw. (T-shaped) incision must be added, the upper end of the longitudinal incision should be selected for it, since the arteries are so much smaller the nearer they are to the vertex. It goes without saying that the same principles apply to the flap operation. In suppurative meningitis, in encephalitis, or in cere- bral abscess free exposure of the foci is always indi- cated. 262 FRACTURES OF SPECIAL REGIONS. Skiagraphy is of great value in fractures of the ver- tex. In the case illustrated by figures 159 and 161 Fig. 163. — Removal of deep-seated splinters, a, Extracting forceps ; /', superficial and depressed splinters; c, deep-seated bone-splinter; d, bone-mar- gin from which the splinters were removed ; e, reversed skin-flap. Fig. 164. — Enlarging fractured area by cutting forceps, a, Protruding bone- portion to be removed by forceps; b, lacerated dura mater ; c, intact dura mater; d, wound-margin of injured bone ; e, reversed skin-flaps ; f, cutting forceps. the depression of the outer and the protrusion of the inner table could be well demonstrated bv the author. JUS T ISSU ED. THIRD EDITION, THOROUGHLY REVISED. A TEXT-BOOK PRACTICE OF MEDICINE BY JAMES M. ANDERS, M.D., PH.D., LL.D. Professor of the Practice of Medicine and of Clinical Medicine in the Medico- Chirurgical College, Philadelphia; Attending Physician to the Medico- Chirurgical and Samaritan Hospitals, Philadelphia, etc. A Magnificent Octavo Volume of \ 287 Pages. Illustrated with Four Colored Plates and Numerous Engravings* Prices: Cloth, $5.50 net; Sheep or Half Morocco, $6.50 net. (^* (^* (^* PRESS NOTICES. " It is a wgrk by which many will profit, for it is both comprehensive and reliable. The work of Dr. Anders is a good one." — New York Medical Journal. " The book is a good one, and for the average general practitioner will be of dis- tinct service for its detail of treatment." — Bulletin of the Johns Hopkins Hospital. " Dr. Anders has produced a very creditable book — one that has come to stay and deserves a wide distribution." — Canada Medical Record. "We have gone over the book carefully and with much pleasure. We thank the author. We feel that he has added to our literature a book of real value — a thoroughly useful book." — Brooklyn Medical Journal. " For clearness of method, conciseness of expression, continuity and crystalline clearness of thought, we have never seen its equal from the pen of an American author. It has never been our lot to more heartily commend and praise a book." — Georgia Journal of Medicine and Surgery. "It is an excellent book, thoroughly up to date, and a reliable guide to the general practitioner."— Canadian Practitioner. t£* &?* &?* Sent postpaid on receipt of price. W. B. SAUNDERS, Publisher, (see other side) 925 Walnut Street, Philadelphia, Pa. Anders' Practice of Medicine, PROFESSIONAL COMMENTS. 'It is an excellent book, --concise, comprehensive, thorough, and up to date, It is a credit to you; but, more than that, it is a credit to the profession of Philadelphia--to us." ^./^/W Professor of the Practice of Medicine and of Clinical Medici** fefferson Medical College, Philadelphia. "I consider Dr. Anders' book not only the best late work on Medical Prac- tice, but by far the best that has ever been published. It is concise, system- atic, thorough, and fully up to date in everything. I consider it a great credit to both the author and the pub- lisher . " President qf Ike Illinois Homeopathic Medical Association FRACTURES OF THE SKULL. 26 As the patient suffered from epileptiform attacks after the injury, which was originally taken for a superficial lesion only, osteoplastic resection was performed fif- teen years later. The condition found at the opera- tion verified the correctness of the skiagraph entirely. The attacks have since stopped (time of observation after operation, one year). The extracranial as well as the intracranial location of bullets has ceased to offer technical difficulties. If Fig. 165. — Relieving of impacted fragment, a, Fragment ; b, elevator ; c, dura mater ; J, opening trephined for introduction of lever ; e, trephined open- ing ; f, reversed skin-flap. bullets are situated in the bones, two skiagraphs at least are required — one to be taken anteriorly or pos- teriorly and the other laterally. By simply crossing their diameters diagonally the distance from the outer surface can be determined. The same principles of localization, more or less modified, apply to the intra- cranial localization of bullets. In extracting- a bullet the author found it useful to measure the distance of the bullet from the nearest 264 FRACTURES OF SPECIAL REGIONS. bone prominence in both skiagraphs ; also to compare the skiagraph with the features of a normal skull. In the case illustrated by figure 1 58 a bullet had entered the right temporal region, and, by passing the orbit transversely, caused traumatic enophthalmos (injury of the sympathetic roots of the ganglion Fig. K -Fracture of the base of the skull. ciliare?). The optic nerve was pierced and consider- able hemorrhage of the choroidea and retina had taken place. Neither the comminution of the orbit nor any injury within the extent of the left antrum Highmori, through which the bullet had taken its course, could be demonstrated by the rays, but the bullet itself was FRACTURES OF THE SKULL. 265 located in the left pterygoid process. The distances were measured during operation simply with a graded probe first, the distance between the nasal bone and the bullet being taken at the first skiagraph, which determined the direction and extent of the skin inci- sion, and then the same distance being taken from the side skiagraph, which dictated the depth of the inci- sion. Although the bullet was embedded in the bone and was surrounded by new bone-tissue, it was not difficult to detect and extract it, after the antrum Highmori had been exposed by osteoplastic resection of its anterior wall. Without the aid of the rays it would have been impossible to trace the bullet. In fact, it was a surprise to the author that it had taken so lone and destructive a course without showing- any other symptoms than a dull continuous pain all over the skull. The bullet was so much compressed that it had altered its longitudinal form into a flat disc, which ex- plains the shape of the bullet in the skiagraph. FRACTURES OF THE BASE OF THE SKULL (Fig. 166) are, with the exception of gunshot fractures, always caused by indirect violence (fall, blow). In many instances a fissure only is produced, the seat of predilection being the lateral margins of the foramen occipitis. From there the fractures often radiate toward the sphenoid and the squamous portion of the temporal bone. Most fractures of the base are simple continuations from the vertex, the force, for instance, being applied to the forehead and the fracture radiating to the base. 266 FRACTURES OF SPECIAL REGIONS. Strictly local signs are absent ; a fact which is well explained by the concealed situation of the fractured area. Signs. — Among the general or indirect signs the most important one is hemorrhage from one ear or from both ears in consequence of the fracture of the petrous portion of the temporal bone and the simulta- Fig. 167. — Fracture of the nose, showing considerable upward displacement, in a man twenty-eight years of age (two days after the injury). neous laceration of the tympanum. Sometimes hem- orrhage from the nose (ethmoidal bone) and pharynx (sphenoid body) are also observed. If the fracture is situated far anteriorly, sometimes ecchymosis develops gradually in the ocular region, especially in the bulbar conjunctiva. In case of con- siderable blood extravasation there is also slight exophthalmos. FRACTURES OF THE SKULL. 267 Sometimes there is a considerable escape of cere- brospinal fluid, the reaction of which is most character- istic, inasmuch as it shows the presence of sugar, of small quantities of albumin, and of a large amount of salt. There is often paralysis of the facial, auditory, oculo- motor, trochlear, and abducens nerves (strabismus). A thorough examination with the ophthalmoscope not infrequently reveals conditions explained by the pres- ence of blood extravasation in the sheath of the optic nerve, which is often produced by fractures within the extent of the optic canal." There may, besides, be those signs of cerebral com- motion, compression, and contusion that have been dis- cussed in connection with fractures of the vertex. (See p. 252.) So far skiagraphy could be relied upon in this frac- ture type only if the injury was well marked and was situated anteriorly. The prognosis of fractures of the base is extremely unfavorable ; infection, as well as destruction of vital areas within the brain, producing fatal meningitis or encephalitis. In tjbe rare event of recovery there usually remains paralysis within the extent of the injured nerve sphere. From an anatomic consideration of the fractures of the base it becomes necessarily evident that they are beyond direct surgical reach. The treatment must be conducted upon general principles, rest and artificial feeding beinpf the main factors to be considered. The discharge of blood and of cerebrospinal fluid must be watched. The meatus should not be irrigated, but must be protected with a thick idoform gauze dressing, 2 68 FRACTURES OF SPECIAL REGIONS. which is kept well saturated with a strong bichlorid solution. The treatment of the cerebral symptoms falls under the same considerations as those that have been treated of under fracture of the vertex. (See p. 257.) FRACTURES OF THE FACIAL BONES are mainly those of the nasal bones, the superior maxilla with the zygoma, and the inferior maxilla. Fractures of the nasal bones (Fig. 167) are caused by direct violence (sometimes by a fall upon the nose ; more frequently, by a blow with the fist or a stick). In far the greater majority of cases the nasal bones themselves and the vomer, but sometimes also the nasal processes of the superior maxilla, as well as of the frontal bone, are involved. Very rarely fractures of the lacrimal and turbinated bones and of the cribri- form plate of the ethmoid bone are observed. In children fracture of the nasal bones is often caused by diving into shallow water. The signs consist in ecchymosis of the nasal dorsum - and in more or less profuse hemorrhage from the nasal cavities. There is always backward displace- ment of the fragments, so that the shape of the nose becomes flattened (traumatic saddle-nose). If the vomer participates, lateral displacement of the nasal frame is also produced. The extensive ecchymosis often veils the nature of this injury. If a fracture is suspected, anesthesia is advisable. The treatment consists in exact reposition, which is best accomplished in the following manner: A dress- FRACTURES OF THE SKULL. 269 ing forceps, the branches of which are kept closed, is introduced and pushed against the inwardly displaced fragments. The manipulations of the forceps are controlled from without by gently pressing the fingers of the left hand on the nasal dorsum. If there should be very much displacement, reposition must be tried by introducing the forceps-branches separately and then compressing the septum in such a manner that the deformity becomes corrected. The reduced frag- ments are kept in situ by "intranasal splints," which Fig. 168. — Dental splint. should consist of rubber drains. They are retained by packing iodoform gauze around them and are secured by small safety-pins. If the latter are affixed to the drain-ends, just where they emerge from the nasal cavities, they serve as a supporting bridge, held in place best by rubber adhesive-plaster strips. If union should have so taken place as to produce deformity, correction can be made by separating the old fracture-lines again with small chisels and nasal bone-forceps. The traumatic saddle-nose can only be 27O FRACTURES OF SPECIAL REGIONS. corrected by partial rhinoplasty, as suggested by Czerny. Fractures of the superior maxilla and the Fig. 169. — Fracture of the alveolar process, caused by a fall from a locomotive on a rail, producing great functional disturbance ; man fifty years of age. zygoma are caused by direct violence (blow by heavy and blunt force — stone, club, base-ball, horse- hoof). The signs are always well marked ; depression, FRACTURES OF THE SKULL. 271 abnormal mobility, and crepitus being present. The line of fracture may be either vertical or transverse. The most frequent type is the fracture of the alveo- lar process, in which the fragments are driven toward the oral cavity. They sometimes remain in loose con- nection with the maxilla, being attached by a small bridge of alveolar tissue. (Fig. 169.) The treatment in all instances consists in reposition, except where the fragment is impacted between the adjoining bones. External wounds being present in Fig. 170. — Transverse fracture of zygoma, caused by a fall from a carriage upon the edge of the sidewalk, in a man of thirty -five years. the greater majority of cases, it is evident that great attention must be directed to thorough asepsis. In gunshot wounds the extraction of splinters has to be considered. Graefe's head-band, which holds the alveolar pro- cess on a grooved steel bar, was formerly the favorite immobilizing medium, but modern practice gives the preference to a dental splint. (Fig. 168.) Fracture of the zygoma (Fig. 170) without displace- ment should simply be treated by rest. But if the zygomatic arch is entirely severed from its connections 272 FRACTURES OF SPECIAL REGIONS. with the maxilla and from the frontal and temporal bones, the considerable displacement resulting there- from requires thorough reposition. In such cases the injury may extend to the orbit. The author observed a case in which pressure of the depressed zygomatic fragment had caused comminution of the orbit, fol- lowed by intracranial abscess formation. Fig. 171. — Fracture of the inferior maxilla. Fractures of the inferior maxilla (Fig. 171) are frequent, and concern its arch in the great majority of cases. They are always caused by direct violence (blow — horse-hoof, stone — or gunshot wound). By in- direct violence (fall on the chin or simultaneous com- pression of both mandibular angles) they are produced but rarely. FRACTURES OF THE SKULL. 273 In children they are uncommon. The head, neck, and coronoid process of this bone are but seldom fractured. The signs are always well marked. There is con- Fig. 172. — Fracture of mental portion of the inferior maxilla in a girl of eleven years, well united, four weeks after the injury. siderable displacement and functional disturbance. Mastication is impossible, deglutition becomes im- 2 74 FRACTURES OF SPECIAL REGIONS. paired, and articulation is indistinct. The saliva is profusely discharged from the oral cavity, which is generally kept wide open. The treatment consists, first of all, in exact reposition. Immobilization is best accomplished then by dental splints made of gold or aluminium molded after a plaster-of-Paris cast. (Compare Fig. 1 68.) If there be but little tendency to displacement, the fragments can sometimes be kept together by winding silver wire around the nearest teeth. In such cases a supporting splint of moss-board, which surrounds the whole exter- nal surface of the mandibular area, does good service. (See p. 66.) In the absence of teeth wiring- of the fragments has to be resorted to. (See p. 69.) Since these fractures are of a compound character, the alveolar tissues always being more or less injured, great attention must be given to the most rigid obser- vation of aseptic principles. Accordingly, careful clean- ing of the teeth, frequent application of a disinfecting mouth-wash (salicylic acid, 0.2 per cent.), and iodoform gauze packing of the wound-cavities are the main therapeutic factors. The diet should be liquid until union becomes per- fect. If asepsis is not carried through in the most rigid manner, infection may cause suppurative periostitis and osteomyelitis, followed by bone-necrosis. It should be remembered that in oral suppurations the respiratory organs are constantly exposed to the dan- ger of infection, many cases of non-complicated frac- tures of the inferior maxilla having ended fatally on account of pneumonia (Schluckpneumonie). FRACTURES OF THE SKULL. 275 Fracture of the Larynx. — Fracture of the larynx is peculiar to the age beyond forty, that being- a period of life in which the laryngeal cartilages begin to calcify. The injury in question affects the thyroid cartilage in the great majority of cases, fractures of the cricoid and arytenoids being extremely rare. It is nearly always caused by direct violence (blow while wrest- ling, attempted strangling). Fracture of the thyroid cartilage may be either uni- lateral or bilateral. The signs consist in ecchymosis, in more or less de- formity, and in abnormal mobility. Crepitus is gener- ally absent, but there is always functional disturbance, the severity of which may vary from slight discomfort to dysphagia and dyspnea. Laryngoscopy generally reveals laceration in the mucous membrane and sub- mucous hematoma. The treatment must especially take into account the dangers of dyspnea. Intubation should be performed without delay. When there is considerable displace- ment of fragments, causing endolaryngeal extravasa- tion and consequent edema, tracheotomy should be resorted to. In the treatment of the sequelae cica- tricial stenosis has to be mainly considered. If such a stenosis should supervene, the permanent employment of a tracheal tube will become necessary. Fracture of the Hyoid Bone. — Fracture of the hyoid bone is produced by the same causes as that of the larynx. It generally takes place at the junction of the corpus with the cornu majus. The signs are also similar to those of fracture of the larynx, but they are usually much less severe, slight hemorrhage from the mouth, hoarseness, painful 276 FRACTURES OF SPECIAL REGIONS. articulation, and deglutition being generally present. Sometimes dyspnea becomes considerable. The treatment consists in manual reposition, the surgeon's left index-finger reducing the fragment while counterpressure is exerted from the outside by the right index-finger and the thumb. If reposition can not thus be accomplished, an external incision must be made upon the fragment, which can then invariably be reduced by a sharp tenaculum, which secures it during the reducing manipulations. The patient must be fed by means of an esophageal tube for at least two weeks, and should be directed to keep silent. APPENDIX. THE PRACTICAL USE OF THE RONTGEN RAYS. The art of skiagraphy can be mastered only after a thorough study of the numerous details of the various apparatus necessary for the production of the Ront- gen rays. Its two first and greatest essentials are a high electric current and a Rontgen vacuum tube. A high current can be obtained in different ways. At present three forms of mechanism are more or less in use : viz., the Ruhmkorff, a simple form of in- duction coil ; the Tesla, or hig-h-tension induction coil, and the static machine. The most efficacious for skiagraphic work is the Ruhmkorff induction coil, which is excited by means of a current derived either from a battery or from a so-called direct current (city supply). A suitable battery, which furnishes a steady current, is the so-called Edison-Lalande cell-battery. For use when traveling, storage batteries may be pre- ferred, the great trouble, however, being that if they become exhausted at a distance from a city, they can not be recharged, while the Edison-Lalande cells can be recharged anywhere. The direct current, of course, is far superior to any other source, since there is neither charging nor super- vising- necessarv. And, last but not least, the direct 277 278 APPENDIX. current never embarrasses the operator by proving- to be inefficient. Accordingly, whenever possible, COn- Fig- 173- — >', Rheostat; /, lever; s, adjustable stand; //, handle; w, wheel of motor apparatus ; a, anode ; c, cathode. nection with the 1 10- or 120- volt direct current should be made. PRACTICAL USE OF RONTGEN RAYS. 279 The stronger the coil, the more efficacious the rays, as a rule. While good skiagraphs can be obtained by small apparatus that give a spark of the length of only six inches, in general large coils giving a spark-length of from 14 to 15 inches are to be preferred. An in- ductor of this power, with a i io-volt direct current, should afford a current-strength of from i to 2 am- peres. The reliability of a Rukmkorff coil (Fig. 1 73) depends upon its thorough construction, and especially upon the proper quality of the wires and the accurate proportion of the windings of the primary and secondary coils. Of special importance is the thorough insulation of the primary from the secondary coil, since any leakage would cause sparking, and would consequently destroy the coil. Into the interior of the coil a condenser is placed for the purpose of intensifying the result. If the apparatus is used in connection with a battery, a vibrator must be adjusted, which controls the peri- odicity of the vibrations. If attached to the direct current, the air-brake wheel should be used, which renders the use of a vibrator unnecessary. The air- brake wheel attachment (Fig. 173, w) permits great rapidity of change in the electric circuit, thus intensify- ing the electromotive force in the secondary coil. It consists of two tooth-wheels, the projections of which are brought into close contact with two flat brushes, which lead the current in and out, while the dentated wheels are rotated at a high speed by a small motor. This motor runs a pressure-blower at the same time, the air-blast from which is directed to a two-forked tube, through which it is led out again by two flat nozles 280 APPENDIX. placed directly above the brushes. There the spark is blown out again by the air-blast as soon as it forms. The current passing- through the coil is controlled by a rheostat. (Fig. 173, r.) By combining this with the air-brake wheel apparatus the electromotive force in the secondary coil is augmented much more than it would be with a simple motor apparatus controlled by a shunt-board provision. The best electric apparatus are made in this country. The alternating current, which is used almost exclus- ively in Europe, requires more complicated apparatus, so that its handling presupposes the experience of a professional electrician. The most important factor, and the one upon the efficiency of which the success of skiagraphy largely depends, is the tube : the higher its vacuum, the more powerful and penetrating the Rontgen rays. The Rontgen tube (Fig. 173) consists of a glass vessel, usually of an oblong or globular shape, from which the air is exhausted and into which the ends of electrodes are fused. With suitable exhaust pumps the rarefaction of the air in the tube can be brought as high as one-millionth part of the ordinary density. One of the electrodes ends in a disc of globular concave shape, which is made of aluminium ; this electrode is called the cathode. (Fig. 173, c.) The other ends in a disc of fiat shape, which is of plati- num ; this is called the anode. (Fig. 173, a.) The anode is situated opposite the cathode at an angle of about forty-five degrees. Its shape may be cir- cular as well as square. Almost all of the modern tubes also contain a second anode, which is connected with the main anode (platinum). (Fig. 173, a.) PRACTICAL USE OF RONTGEN RAYS. 251 One of the great difficulties encountered in the use of the tubes is due to their soon becoming- inefficient on account of the permanent change of pressure that occurs within them. In view of this variation of the intratubal pressure, tubes have been constructed that permit lowering and raising of the vacuum in the tube at will. Siemens found that the fluorescing air, with the vapors of phos- phorus, iodin, and other similar substances, forms dense bodies, thereby diminishing the pressure within the tube. On the other hand, if the walls of the tube are warmed, the stratum of air that condenses on the glass surface is driven away, thereby intensi- fying the pressure. In utilizing this principle tubes with adjustable vacuum have been constructed, which are provided with an adjuster intensifying and dimin- ishing the vacuum at will by lengthening and shortening the space between its spark-rods. If currents of very high intensity are used, the plati- num disc of almost all tubes becomes white hot after a short time (often after a few seconds). If thus kept glowing a little longer, the platinum melts. To ob- viate this most embarrassing occurrence, tubes have recently been constructed in which the metallic parts are very thick and resistant. Such tubes permit of a current of maximum intensity for about one minute ; then the very marked outlines of the pic- ture become less distinct, the tube filling- with blue light at the same time, which indicates that it is overheated ; the current must then be turned off with- out delay. Such tubes make a good skiagraph of the thorax, for instance, in forty-five seconds. Grun- mach constructed tubes that permit the glowing metal 252 APPENDIX. to be cooled by the intratubal circulation of a stream of cold water. The best tubes are undoubtedly those that, when just purchased, show a red-hot focus at the platinum disc while a low current is employed. New tubes that show fluorescence only by using a high current should invariably be rejected. It is one of the main character- istics of a orood tube that it stands intense trlowine of the platinum disc without being impaired at once ; in other words, that it stands currents of high intensity. A "food tube must also furnish a uniform liofht. The variety of tubes manufactured now in various parts of the world is very great. The best are made in Thuringen (Germany). It requires a vast amount of experience and repeated experimentation to select tubes suitable for the particular apparatus to be employed. So it must be considered that static machines require tubes with a special vacuum, while tubes prepared for a battery-set generally do not give satisfaction with an air-brake wheel apparatus or a Wehnelt interruptor, which permits the use of tubes of the highest vacuum obtainable at present. The vacuum of the tubes is generally increased dur- ing their use, which necessitates a proportional increase of the intensity of the current. Therefore, even for in- ductors furnishing a very long spark, tubes with a low vacuum should be chosen, as the latter increases so much during use that at last the full power of the appa- ratus is required for producing an efficient light. Fin- ally, however, the fluorescence of the tube ceases, even if the high current is employed. Then the vacuum can be reduced by heating the tube with an alcohol- lamp, while a weak current is used, until the fluores- PRACTICAL USE OF RONTGEN RAYS. 283 cence becomes distinct a^ain. If this fails, the tube should be surrounded evenly and tightly by gauze compresses slightly moistened with water. At last, of course, all these procedures will prove to be without avail. Some tubes regain their efficiency simply by being left untouched for a few weeks, but finally they all become useless for medical purposes. Then the resistance of the tube becomes so great that, while the interior hardly shows any fluorescence, most of the sparks go around the exterior surface of the tube. The presence of purple or red light points to a leak, which naturally renders the tube inefficient. Leaky tubes may be repaired by sealing the defect. The tubes must be preserved in a closet in which there is a uniform medium temperature. They should rest on padded shelves. Dust, which in the course of time always becomes adherent to the tube while in use, is to be wiped off by passing the dry palm of the hand gently over it. The degree of intensity of the tubal light and the amount of penetration can be estimated by an experi- enced operator simply by holding his own hand before the fluorescing screen. For exact measurement, how- ever, various kinds of skiameters have been devised, the principle of which consists in the attachment of small squares of tinfoil, of varying thickness, to a fluor- escing screen. The difference of thickness is indicated by little figures, made of lead, which appear more or less distinct according to the thickness of their corre- sponding tinfoil. The author found it useful to con- struct a skiameter consisting of fifty staniol discs, ac- cording to the number of knobs at his rheostat. (Fig. 284 APPENDIX. 173, r) To each disc a number, made of wire, is attached, which indicates the number of the staniol lamellae. No. 1, for instance, contains one lamella only, while No. 50 contains fifty. That number which just permits of the recognition of the shade of its wire cipher indicates the degree of intensity of the tube. If the rays fall upon a screen covered with fluores- cing salts, such as tungstate of calcium, platinocyanid of potassium, or platinocyanid of barium, fluorescence is caused on it. The human hand, for instance, if placed between the tube and a screen evenly covered with one of the fluorescing salts, shows the condition of its bones distinctly. Even the soft tissues can be distinguished to some extent. The use of the fluorescing screen is facilitated by attaching it to a suitable framework, formed like a ster- eoscope, the body of which is of tapering form. The large end of such an instrument, generally called flu- oroscope, should contain a piece of cardboard, on the inner surface of which the fluorescent salt is distributed, while the small end has two apertures, formed in such a manner as to fit over the eyes of the operator. With the fluoroscope a superficial examination of the objects can be made. Movable organs — as, for instance, joints, larynx, hyoid bone, or the intrathoracic viscera (especially the diaphragm, heart, and pericar- dium) — can be studied while moving or pulsating. But the numerous fluorescing impressions, succeed- ing each other with great rapidity, are apt to deceive the human eye wherever the features of the lesion are not distinctly marked ; while fixation on a photographic plate gives all the details exactly. Therefore, fluor- oscopy should be used in fractures as a preliminary PRACTICAL USE OF RONTGEX RAYS. 285 procedure only. It calls attention to the seat of the fracture, and determines the best position of the limb for proper fixation. Especially in joint fractures it will select that angle of flexion or extension in which the injured portion can be brought out best on the plate. It is the plate only which shows the details of the fracture exactly and which permits of the thorough study of the various features of the fracture type. Its comparison with the normal skeleton will make the abnormalities evident at once and will help the sur- geon to a thorough judgment of the case ; and the value of a skiagraph for future information — some- times for forensic purposes — should not be underes- timated. Therefore, whenever exactness of result is desired, fixation on a pliotographic plate is to be preferred." The photographic technic can easily be learned. The development of a skiagraphic plate is practi- cally the same as that of an ordinary photographic one exposed to sunlight. There is no doubt that the anatomic knowledge of a physician makes him more fit to develop the important parts of a plate more in- tensely. It is, besides, a great advantage if the phy- sician is able to develop the plates himself, since he is enabled to learn the result at once, while sending the plate to a photographer involves a great loss of time. Notwithstanding this fact, the author, believing that a skilled operator can do more exact work than the medi- cal amateur, prefers to have the valuable assistance of a professional photographer, and therefore has his plates developed by the most skilful experts available. In taking skiagraphs properly a number of small details should be considered. First of all, it should 286 APPENDIX. be borne in mind that it is a law, applicable to all ele- ments, that the higher their atomic weight, the more energetic the absorption of the rays. The organic substances of the body, such as the salts of lime in the bones, absorb more light than the surrounding soft tissues, consequently they are but slightly permeable. The more lime-salts the bone contains, the less perme- ability exists and the more distinct its silhouette will be on the photographic plate. Compact bone-tissue thus shows a much more distinct picture than the medullary or spongy parts. (See Figs. 1 19 and 135.) The special structure of the different bones can be recognized so well, in fact, that the study of the trans- formation of bone-tissue is no longer based upon mere conjecture. The organic tissues of the human body show per- meability of a medium degree. The muscular layer of the heart, or of a hand or foot of ordinary size, has a permeability about the same as that of a liver or kidney of the same thickness. The tissues of the nerves and the blood-vessels are a little less per- meable. This explains why in skiagraphs of the soft parts no particular variety of tissue, as of muscle, ten- don, ligament, nerves, or vessels, is distinctly marked. When one or another tissue appears more distinct, this fact may be attributed mainly to the greater thick- ness of the mass of the tissue in question, and less to its own character. About the same degree of perme- ability is shown by hyaline cartilage and by normal blood as by that which is decomposed. In a good skiagraph all kinds of metal (bullet, needle, nails), stone, wood, and glass will be shown. The weight of the smallest splinter of iron so far dem- PRACTICAL USE OF RONTGEN RAYS. 287 onstrated was 0.0202 gm. Calcified trichinae also show easily. All varieties of fractures and their complications, callus formations, and dislocations are representable. After osteoplastic resection the result can be ascer- tained by the rays. Months after osteoplastic ampu- tation of a leg the author was able to demonstrate the small bone-fragments which were bent inward from the cortex of the tibia and fibula for the purpose of making a solid stump. The differentiation between bony and fbrous anky- losis is now as easy as it is important. (See Fig. 1 19.) In the treatment of congenital dislocation of the hip the skiagram will determine what method of treatment should be chosen, as it reveals well the relations be- tween the femur and the acetabulum. If the condition of the latter be unfavorable, bloodless reduction will be impossible, and a cutting operation must be per- formed. The skiagram will also demonstrate whether reduction of a hip dislocation was successful or not. It is true that after perfect reduction the head of the femur can be felt between the spina and the symphysis in the majority of cases, and also that the characteris- tic noise can be perceived while the head is jumping over the margin of the acetabulum. But, on the other hand, it can not be denied that the noise is often indis- tinct, and that the thickness of the muscles oftentimes impairs our judgment, so that it is the skiagram only which gives indisputable information. In the various forms of talipes and in floating bodies in the knee-joint the rays are also serviceable. Rachitic deformities can also be well represented. Particularly in obstetrics, the study of a rachitic pelvis is of great importance. 288 APPENDIX. Differentiation is easily made between the osseous and articular changes in acromegaly and osteoarthro- pathie hypertropliiante pneumique. The author has succeeded in obtaining undeniable signs of fracture of the coccyx in two cases of alleged coccygodynia. The conclusion is obvious that in most of the cases which were taken lor coccygodynia, and which were preceded by trauma, a fracture or infrac- tion had Occurred. Inflammatory processes — spondylitis, for instance — can easily be differentiated from fractures of the spinal column, and tubercular foci in the bones can also be represented. The same applies to osteomyelitis (see Fig. 142) and necrosis. Iodoform- glycerin injected into tubercular joints can be recognized as a distinct shadow, and thus may some- times oqve evidence of the extent of fistulous tracts. The cartilages of joints are permeable to the rays ; but if they atrophy on account of arthritic processes, a skiagram of the same appearance as that of ankylo- sis is obtained. The interspace always found between two bones of a joint under normal conditions has then disappeared. The differentiation between diseased cartilage and ankylosis is easy, as in the last event mobility is arrested. Deficiencies of the skull, especially such as those caused by syphilis, are an interesting object for skiag- raphy. Differentiation between simple arthritis, rheumatism, and tubercular and syphilitic affections of the joints is also possible. Foreign bodies in the skull or in the eye are easily reproduced. PRACTICAL USE OF RONTGEN RAYS. 289 Solid tumors, such as osteomas, osteochondromas, osteosarcomas, enchondromas, and fibromas are also well represented. In a case of aneurysm of the thigh, in which the entire absence of pulsation was a per- plexing feature, the author failed to get any posi- tive information as to the character of the tumor. Still, the rays were found to be of great value, inas- much as they excluded several possibilities in the case — viz., osteoma, osteochondroma, and osteosarcoma — for which the hard immovable growth could have been mistaken. But, considering that in the event of the presence of a growth of this character the skiagraph would not have shown the outlines of the bone normal and distinct, they were excluded. In aneurysm of the thigh the thick femoral muscles of course veil the out- lines of the aneurysm-wall, while the structure and out- lines of the bone would distinctly show. :|: In thoracic surgery skiagraphy has proved that after subperiosteal resection of a rib the exsected portion is always more or less re-formed. f The extent of a pyothoracic cavity can be repre- sented by filling it with iodoform-glycerin. The sub- nitrate of bismuth, which is not permeable by the rays, furnishes a still more marked contrast; but as it inter- feres with the treatment, its use can not be recom- mended by the author for this special purpose. Pleuritic effusions show a marked opacity through the fluoroscope. The larger the amount of effusion, * Compare the author's article on the difficulty of differentiating be- tween femoral aneurysm and osteosarcoma in " International Clinics," vol. iv, Ninth Series. f Compare the author's article on " Pyothorax," in the " International Medical Magazine," for January, 1897. 19 29O APPENDIX. the greater the degree of opacity. In pyothorax the opacity is somewhat less complete than in serothorax. Especially on the right side, the outlines of the liver show a marked contrast to the lower boundary-line of the effusion. The upper boundary-line of the effusion generally appears convex, but if the patient inspires deeply, or if he coughs violently, it loses its convexity and becomes horizontal. By changing the position of the patient, of course, displacements of the effusion are observed accordingly. Uniform transparency above the effusion points to the result of a simple inflamma- tory process, while constant opacities of an irregular appearance justify a suspicion of beginning tuberculosis. As a rule, it is found that the area of dullness corre- sponds to the area of the shadow. It is natural that the representation of calcareous areas, as well as of cavities, in tuberculous lungs should not be attended with any technical difficulties. Mediastinal and pul- monic tumors which on percussion did not show any dull area pointing to their presence are recognized. Swollen bronchial glands have also been diagnosti- cated by the rays. Hypertrophied pleurce show a very distinct shadow, which is as thick as liver-tissue. This renders exploratory pleurotomy, advised by the author, * entirely unnecessary. Hydropneunwthorax may also be recognized by the rays, which show the very dark outlines of the exuda- tion in contrast to the lio-ht shade of that intrathoracic area which contains air. The dark boundary-line of the exudation can be recognized by the fluoroscope as an ascending and descending line during expiration. *See "Exploratory Pleurotomy and Resection of Costal Pleura," " New York Medical Journal," June 15, 1895. PRACTICAL USE OF RONTGEN RAYS. 29 1 The diagnosis of subphrenic abscess, formerly so difficult,* has become simple, the space between the diaphragm and the lower boundary-lines of the abscess showing distinctly. If situated between the diaphragm and the liver, the image is particularly distinct.*!* The localization of lung-abscess is simplified by skia- graphing in different positions. The position, size, and shape of the Jieari can be elicited. There is also no difficulty in differentiating aortic aneurysm from mediastinal tumor. Indeed, as to type, shape, and size of any medias- tinal tumor, much more reliable information can be obtained by skiagraphy than by percussion. In a case of aortic aneurysm\ the author could demonstrate not only complete atrophy of the sternum down to the xiphoid process, and of the sternal portions of the clavicle, but also the overlapping of the heart over the parasternal line and the downward displacement of its apex. The oval shape of the heart was distinctly recognizable, and was well demarcated from the aneurysm, the enormous intrathoracic extent of which was also clearly shown. Another skiagram of the same case showed the aortic arch. The patient having succumbed to pneumonia six months after his case was demonstrated, the author had a chance to verify the correctness of the skiagrams by the autopsy. * Compare the author's article on " Subphrenic Abscess," " Medical Record," February 15, 1896. + Compare the author's " Beitrag zur Literatur der subphrenischen Abscesse," " Langenbeck's Archiv," vol. lii, No. 3 ; and " The Ront- gen Rays in Surgery," " International Medical Magazine," May, 1897. i Compare the author's article on " An Extraordinary Case of Aortic Aneurysm," " New York Medical Journal," April 15, 1899. 292 APPENDIX. If we realize that the rays enable us now to recog- nize aneurysms at their earliest stages, it becomes evident that frequently a series of prophylactic meas- ures can be employed which may counteract any further aneurysm-formation. The therapeusis then being under perfect control, it can be ascertained whether, under treatment, either improvement, arrest, or still further expansion may take place. It is evident that in all these cases, especially in accumulations of fluids, the question of displacement of the heart is of great importance for diagnosis. Bullets in the thoracic cavity are represented with difficulty. It is only when the patient possesses enough energy to inspire deeply and to retain breath for half a minute that a foreign body in the lungs or pericardium can be made visible. The diagnosis of arteriosclerosis, while very easy on the surfaces of the body, was very difficult in the deeper tissues. According to the text-books on in- ternal medicine, the thickening of the tunica intima can not be recognized if it be confined to a small area or to single small foci. It hardly need be em- phasized how important it is to know whether, in a given case of sclerosis of the radial artery, for instance, there exist foci in other vessels besides. Nor can it be a matter of indifference what the number of these obstructive foci is, and whether a large artery, such as the aorta, or only a small one, such as the temporalis, is concerned. The presence of a large number of foci means a loss of propelling energy in the circulation, which can be compensated only by the increased work- ing power of the left ventricle. The arterial pressure thus becoming higher, hypertrophy of the overworked PRACTICAL USE OF RONTGEN RAYS. 293 ventricle will be the most natural consequence. If such foci are recognized at an early stage, proper prophyl- axis can accomplish a great deal in preventing secon- dary disturbances. The prognostic significance of an exact knowledge of the condition of the arteries is also evident. The Ront^en ravs give us a most reliable method of ascertaining the condition of the vessels, and this in nearly every part of the body. In a case of sclerosis of both radial arteries the author studied the forearm, head, neck, and femoral and aortic regions skiagraphically. Nowhere did the conspicuously de- veloped plates show any indications of degeneration of any artery except on the forearm. From the nega- tive state of the other skiagraphs the author drew the conclusion that the patient's arteriosclerosis was con- fined to the radialis and anterior interossea — a limita- tion which harmonized with the good general condition and the absence of palpitation, dyspnea, and vertigo. * Enchondroma of the larynx can be easily recog- nized. Aneurysm of the carotid, the subclavian, the anonyma, and the abdominal aorta are also represent- able. In abdominal skiagraphy great progress has also been mad erecently. Total transposition of the viscera could be well represented by the author.-j* The stom- ach, the intestine, and the bladder are of equal trans- lucency, and skiagraphs of these organs have to be taken cum prano salis. The much more solid masses of the liver, the spleen, and the kidneys can be well represented. In a case of carcinoma of the pylorus in which the * Compare the " New York Medical Journal," January 22, 1898. f" Annals of Surgery," May, 1899. 294 APPENDIX. author performed a successful pylorectomy, a distinct shade had been obtained. To make the outlines of the stomach visible, the stomach may be filled with salts which are imperme- able to the rays — subnitrate of bismuth, for instance. The author, however, prefers the introduction of a soft rubber tube the lumen of which is filled with mercury. Of course, in a tube of this kind an eye must not be cut out. A rubber tube containing thin, flexible steel wire in spiral form, advised by the author,* permits of rapid representation of the outlines of the stomach. The stoppage of this tube indicates its arrival at the large curvature of the stomach, and further propulsion shifts it alongside its wall. There the steel spiral is easily shown by the skiagraph. In carcinoma of the esophagus the author has tried the same experiment with smaller sounds, but, unfortunately, few patients are able to tolerate them for a length of time sufficient for good representation. Hydronephrosis and echiuococcus were reported as being recognized in connection with the usual diagnos- tic methods. Renal and vesical calculi may also be skiagraphed. In the living subject, with the old vacuum tubes only such calculi could be represented as consisted of a hard and firm layer, like the oxalates, while the more penetrable urates left an indistinct shadow, and the translucent phosphates hardly showed at all. The success of skiagraphy in calculi of the urinary tract depended only upon the different chemic composition of the calculi, and consequently upon their greater or * See "The Rontgen Rays in Surgery," "International Medical Magazine," May, 1897. PRACTICAL USE OF RONTGEN RAYS. 295 less opacity.* Now, with the new quick-penetrating tubes, more or less opaque shadows of all three dif- ferent varieties can be obtained. Gall-stones could not be skiagraphed until recently. It was the privilege of the author to show the first un- disputed skiagraph of gall-stones in the living subject at the October meeting of the New York County Medical Association, in 1899. Gocht, Oberst, Rumpf, Dumstrey, and Metzger, who are among the best-known experts in skiagraphy, declared recently that biliary calculi could not be represented. The last-named is even responsible for the bold assertion that " nowa- days nobody will any longer maintain that gall-stones can be skiagraphed"; that "all experiments in this direction have proved to be failures"; and that "it appears hopeless that such experiments will give any other result in the future." But errare humanum est ! After many trying disappointments the author suc- ceeded for the first time in skiagraphing the chole- lithiasis of a woman seventy-two years of age, after hav- ing employed four different photographic plates at the same time. The upper plate, situated directly below the region of the orall-bladder, showed the outlines of the liver well, while in the fourth and remotest plate it appeared only faintly ; but the calculi were clearly represented. The next exposure was made with a quick-penetrating focus-tube on a single plate, and lasted ten minutes. After it was found how long it took with this tube to represent the liver and the os ilii, a second plate was exposed, this time for six * Compare the author's previous publications on this subject : " Inter- national Medical Magazine," May, 1897 ; and "American Journal of Cutaneous and Genito-urinary Diseases," January, 1899. 296 APPENDIX. minutes only. This second skiagraph showed the denser tissues less clearly, while the calculi were much more distinct. An exposure lasting seven minutes, one for eight minutes, and one for nine minutes were also made, all showing- that the longer the time of exposure, the clearer the denser tissues and the obscurer the calculi appeared. It thus became evident that one exposure is not sufficient to determine the length of time required by each individual tube for the representation of each individual gall-stone type. A test should therefore be made first by making a short as well as a long exposure in a case of suspected cholelithiasis ; that is, an exposure of about four min- utes as well as one of nine or ten. The most powerful focus-tubes at present attainable should be chosen for the purpose. By comparing the results the proper time of exposure for the best results can be estimated. For better identification the contours of the organs, especially the liver, should be outlined by thin wire at- tached to the plate before the final skiagram is taken. The results, of course, are to some extent dependent upon the chemic composition of the bilia7y calculi, which is far more complex than that of calculi in the urinary tract. All the different types of calculus were skia- graphed by the author on a photographic plate, in order to obtain a visual comparison of their perme- ability. The same calculi were then irradiated through the living body, thus practically demonstrating the dif- ference in translucency. The common biliary calculi, the most frequent type, were found permeable to the rays, and therefore produced a light shade only. If present in large numbers, the shade was somewhat more conspicuous. Calculi composed of pure choles- PRACTICAL USE OF RONTGEN RAYS. 297 terin are less permeable to the rays than the common type, and show a slightly more distinct shade. The stratified cholesterin calculi, on account of their admixture of calcium, show much less permeability to the rays, wherefore a distinct skiagraph can be counted upon. The mixed bilirubin calculi, which, besides bilirubin- calcium, contain traces of copper and iron, are less permeable to the rays than all the former varieties, and consequently give a very distinct shade. The same applies to the pure bilirubin-calcium calculi. In skiagraphing the gall-bladder it is necessary that the patient should lie on his abdomen with a pillow underneath his symphysis as well as under- neath his clavicle. The elevation produced by these pillows permits the protrusion of the region of the gall-bladder, thus bringing the calculi nearer to the photographic plate. The approximation is increased by turning the body slightly to the right and raising the left side. Another point of importance is that the rays should not penetrate the abdomen in a vertical direction, but from the side, so that the thick and less transparent tissue of the liver is not permeated in its whole diam- eter. The direction of the rays should be such that they form an angle of about sixty degrees with the plate. The tube must be as near the abdomen as possible. By employing this method, not only the size, shape, and diameter of the gall-stones can be determined, but they can also be localized. How important it is to know whether there are also calculi in the liver besides those present in the gall-bladder! Calculi in the com- 298 APPENDIX. mon duct can also be shown, while formerly it was only after extensive exposure by laparotomy that such diagnosis could be made with any degree of certainty. Exploratory laparotomy for suspected cholelithiasis will hardly be necessary any more. If medical treatment of cholelithiasis is tried on the basis of a skiagraph, it can be ascertained by subse- quent exposures whether any calculi were dislodged or whether some had escaped into the duodenum. The same applies to the state of the intrahepatic calculi. If the calculi prove to be of very large size, their re- moval by medical treatment can naturally not be ex- pected. Since his latest publication * the author has had fre- quent opportunities to skiagraph biliary calculi, and with the improvement in the routine, the skiagrams became much clearer. In a case of cholelithiasis in which cholecystotomy was performed by the author, pure cholesterin calculi were found, which, in spite of their transparency, had made a well-defined shadow on the plate before operation was resorted to. The question whether or not an operation should be performed in cholelithiasis can thus be definitely set- tled by the Rontgen rays. When small stones are represented, there is a chance for medical treatment. When stones are found too large to pass the common duct, medical treatment can only be of a palliative character, and cholecystotomy should be performed as soon as the calculi prove to be a source of irritation. As previously mentioned, an excellent tube is the * " On the Detection of Calculi in the Liver and Gall-bladder," " New York Medical Journal," January 20, 1900. PRACTICAL USE OF RONTGEN RAYS. 299 conditio sine qua non for skiagraphic success in such delicate work. But even the best tubes differ in their qualities, and must, therefore, be studied and, so to say, individualized, as different patients are to be judged differently, although suffering from the same disease. Absolute laws can therefore not be made. (Compare p. 305.) In general, it may be said that the more translucent a calculus, the shorter must be the exposure ; therefore the pure cholesterin calculus re- quires a shorter exposure than one containing calcium. But the great trouble is that when skiagraphing for suspected calculi, we do not know beforehand what may be the chemic composition of the alleged stones, and therefore we do not know what time of exposure will be the most desirable. This difficulty can be overcome to some extent by making a minimum and a maximum exposure at the same time. If a short ex- posure reveals the presence of calculi, while a long exposure, made at the same time, is negative, the prob- ability is that a translucent calculus (cholesterin) is present. If a short exposure proves to be positive and a small one negative, a dense calculus may be inferred. Even a poor negative, if it shows nothing but the faint outlines of elliptic and faceted bodies in the re- gion of the ofall-bladder, is authoritative. Sometimes the negative shows nothing but the calculi. They must always be most carefully studied, because the in- experienced eye often will not recognize the calculi, which are evident to the trained eye at a glance. All authors agree that one of the greatest difficul- ties encountered in the treatment of spina bifida has been the fact that its various types — viz., simple menin- gocele, myelomeningocele, and myelocystocele — could 2,00 APPENDIX. not be differentiated. Especially, the distinction be- tween meningocele and myelocystocele has been gener- ally impossible. Considering only the one point that in meningocele aspiration should be tried first, while in the other varieties extirpation must be resorted to, the importance of the question is self-evident. The skia- gram now shows with absolute distinctness whether or not there is an opening in the spinal column ; it shows also the presence or absence of the nerve-substance, and sometimes even its expansion in the sac. In those rare cases in which the presence of lipoma or fibro- myoma is in question it is again the skiagram which gives the needed information.* Soon after the utilization of Rontgen's discovery, reports of extensive dermatitis and gangrene of the integument were published, which disturbed the public mind in a deplorable and unjustifiable manner. But, especially since the time of exposure is now so much shorter than during the earlier stages of the art, the possibility of originating skin irritation is extremely small. It is undeniable that a peculiar trophoneurotic idio- syncrasy may exist in some individuals, but in the great majority of known cases the burns of the skin were caused either by the ignorance of the unskilful operator, the tube often being too near the object, or by too prolonged and too often repeated exposures. It is not surprising to observe such accidents so long as laymen, such as opticians and instrument-makers, who understand nothing of the anatomy and physiology * Compare the author's article on " The Rontgen Rays in Spina Bif- ida," " Medical Record," August 13, 1898. PRACTICAL USE OF RONTGEN RAYS. 3OI of the skin, are intrusted with "the manufacture of skiagrams." As in many other respects, the question of proper dosage must also here be perfectly understood by the operator. A person who irradiates a patient suffering from sycosis every day intensely for a whole hour, irrespective of the reaction following such a radical procedure, so that gangrene occurs, has just as little business to do skiagraphic work as a shoemaker has to prescribe morphin. Since February, 1896, the author has made nearly three thousand skiagraphs, and has never observed the slightest irritation of the skin in any case in which the rays were used for diagnostic purposes. In two cases only was circumscribed depilation observed. In both patients the skull had to be skiagraphed fre- quently and at short intervals (one was the case illus- trated by Fig. 161, and the other that shown in Fig. 172). In the first case depilation began after the fifth, and in the second case after the sixth, exposure. In both instances the hair was perfectly restored three weeks afterward. Changes in the pigmentation of the integument or in the growth of the finger-nails, congestion, inflam- mation, and necrosis of the skin are reported. Some operators have observed cessation of perspiration on the dorsum of their hands. The source of such tissue-changes is like that of other burns produced by electricity. It was not more than natural that these properties of the rays were soon utilized for tJierapeutic pur- poses. Cases of hypertrichosis, of ncevus vasculosis, of all the various types of eczema, psoriasis, and syco- 102 APPENDIX. sis, have been reported as cured by the rays. There can also be no doubt that parasitic skin-diseases, such as lupus vulgaris and erythematosis, yield to the rays. Sycosis parasitica as well as non-par asitica and favus have been cured after one exposure. In a case of sycosis parasitica which had existed for six years, and had resisted the usual methods of treat- ment, the author observed a perfect cure after an exposure which lasted seven minutes only. In a case of lupus of the inguinal region the author observed a perfect result. After the sixth exposure inflammation of the lupous area began, and the nodules shelled out, so to say, together with the destroyed tis- sue. In their place a light red ulcus remained, which bled on the slightest touch, and which did not cicatrize until nine months after the last exposure. In such cases transplantation is generally indicated. It goes without saying that this mode of treatment, while most effective, is very annoying to the patient, whose grati- tude to the physician is somewhat restricted on that account, even after perfect recovery. In some of the cases reported the nodules did not shell out, but shrunk, presenting the appearance of having been painted with varnish. A great deal can, however, be done to limit the ill consequences of the irradiation treatment of skin dis- eases, which should not be resorted to unless all other therapeutic measures have been exhausted. Under proper precautions the ill effects of the rays can be avoided. In the first place, the healthy parts in the vicinity of the diseased area should be protected by sheets of staniol. Then the patient's subjective condi- tion should be carefully watched. As soon as there is PRACTICAL USE OF RONTGEN RAYS. j^j a slight bu rnino- sensation or itching within the irra- diated sphere, further exposures must be stopped. For therapeutic purposes the tube should be as near to the diseased area as possible, and the time of the first exposure should not be longer than ten minutes. Later on, when no reaction shows, the irradiation may be kept up for from twenty to thirty minutes. In lupus as many as fifty exposures may be necessary until the nodules are destroyed. In obstinate cases exposures may be made daily. During the intervals the diseased area should be powdered with amylum or dermatol. In the event of relapse, the same treatment must be commenced again. It is necessary to individualize just the same as in other therapeutic indications. Some individuals show signs of irritation after a few exposures, and others do not react until after frequently repeated and intense irradiations. At first these remarkable results were explained on the theory of bactericidal influence of the rays. But it seems that their effect is of a decidedly electrochemic character, the congestion caused by the irradiation being mainly responsible, just like the artificial hyper- emia in tuberculosis. In disturbed nutrition of the skin the inflammatory reaction produced by the rays would set up an alteration in the circulation of the affected spheres. Bacteriologic experiments have shown that the rays, applied directly after inoculation with anthrax bacilli, as well as with streptococci and staphylococci, had no effect. But pure cultures of cholera, typhus, and diph- theria died after forty-eight minutes' exposure to in- 304 APPENDIX. tense irradiation. It seems that various bacteria react differently according to the quality of the plasma and the degree of the fluid they contain. Dentistry has also profited considerably by the rays. The relation of the dental roots and their position, the presence or absence of the milk-teeth as well as of the permanent teeth in children, or of an old root, and foreign bodies (fillings, pieces of chisel broken off, for instance, while excavating a carious tooth) can be clearly demonstrated. Sometimes it is of great forensic importance to de- termine the age of an infantile corpse by skiagraphing the teeth. As a rule, it will suffice to place the face portion nearest to the tooth in question on an ordinary Ront- gen plate. If fine details are demanded, flexible films may be introduced into the oral cavity, where they will adapt themselves to the contours of the maxilla. It has been reported that certain types of neuralgia are benefited by long exposures. As stated before, the intensity of the rays increases in proportion to the height of the vacuum. If very high vacua are used, even the bones of the hand may be- come so translucent that they can hardly be distin- guished on the plate. Thus it will be easily under- stood why, for the representation of the bones of the hand, a tube with a low vacuum (so-called mild or soft tube) is to be chosen, while if the rays have to per- meate a very thick body, such, for instance, as the pelvis of a fat person, it is the high vacuum tube (hard tube) only that would be capable of throwing so much light through it as to show a well-defined PRACTICAL USE OF RONTGEX RAYS. 305 shade on the plate. From this we learn that, accord- ing to the thickness and permeability of the object to be skiagraphed, tubes of low, high, and very high vacuum must be at hand. Recently, tubes have been constructed by Gunde- lach which permit of regulation by the diffusion of hydrogen. Into the wall of a tube of this kind a small platinum wire is fused, the end of which protrudes outside to the extent of two inches. If this protruding piece of platinum is heated by a Bunsen burner, the hydrogen of the flame diffuses into the interior of the tube, thus auomientinof the intratubal vacuum at will. The heating process must be kept up from one-half to three minutes. The handling of these tubes is troublesome, but their usefulness is great. Another most important factor that affects the dis- tinctness of a skiagraph is the length of time of tJie exposure. If the most perfect apparatus is used, the hand of an adult can be well represented in less than half a minute, while the forearm requires one minute and a half. The elbow, humerus, and foot, at an average, need from two to two and one-half minutes, and the lee, knee, and thorax, from three to four minutes ; while for the shoulder and thigh from four to five, for the skull from five to six, and for the pelvis from six to ten, minutes are generally necessary. The capacity of a tube is tried best by using it for different lengths of time — viz., for twenty, lorty, or sixty seconds — on the same subject, and determining its penetrating power by comparison of the skiagraphs. In children the time of exposure must be lessened, in view of the greater translucency of the bones. The distance of the plate from the tube also deserves 306 APPENDIX. great attention. Different distances give different re- lations, and the less the distance between plate and tube, the larger the silhouette of the body ; but the smaller the silhouette, the more correct the anatomic proportion of the tissues. The more distant the tube is placed, the longer the time of exposure must last. On an average, an equally good skiagraph of the hand is produced when the distance is six inches and when the exposure has lasted half a minute, as when the distance was twelve inches and the exposure a whole minute. For locating foreign bodies, apparatus have been devised by Hoffmann, Levy-Dorn, Sehrwald, and Angerer. The author has thus far been able to locate foreign bodies in the simple manner described on page 265. The wire letters used for registration (p. 311) can also be used as landmarks ; one, for example, being placed above the plate below the wound or scar signifying the entrance of the foreign body, and others at proper intervals on the plate as well as on the sur- face of the limb. For localization on the skull, wire- may be wound around the head, and at various inter- vals ciphers (compare p. 265) may be spread as land- marks. The same means may be employed on an extremity, where wires may be wound around, and ciphers put on the limb as well as on the plate. The same principles apply to other parts of the body in proper modification. The objects to be skiagraphed must be in close con- tact with the photographic plate. As far as their posi- tion is concerned, it is advisable to take the forearm in supination, although this position is by no means the most comfortable one for the patient. The upper PRACTICAL USE OF RONTGEN RAYS. 307 arm and the thigh can be taken in any position. The leg should be skiagraphed while its external surface rests on its support, the knee being bent and the thigh rotated. The foot, from the toes up to the upper third of the metatarsus, is best photographed in the direction of the dorsum toward the planta pedis. Further back the first and third cuneiform bones and the scaphoid present an obstacle, so that it is advisable to illuminate the foot on these portions transversely by having the outer surface rest on the plate. By this procedure the isolated shadows of the astragalus, the calcaneum, the os cuboideum, the scaphoid, and the fourth and fifth metatarsal bones can be seen. The hand is taken from the dorsum through to the palm. The knee-joint rests preferably on the external condyle. The humero- ulnar joint should be taken transversely, while the Jnunero-radial joint had better be illuminated from the flexor to the extensor side. The hip-joint is taken best by turning the patient from his recumbent posi- tion inwardly, so that the anterior axis of the thigh forms an angle of from thirty to forty degrees to the underlying plate. The opposite hip is elevated and supported accordingly. With respect to the position of the tube, care should be taken to have the center of the platinum disc exactly above the center of the plate upon which the object rests. In order to judge a skiagraph thoroughly, the source of the current (whether battery or street), the length of the spark of the induction coil (whether a vibrator or an air-blast is used), the intensity of the tube, the dis- tance of the platinum disc of the tube from the photo- graphic plate, the position of the object, the sort of 308 APPENDIX. plate used, and the time of exposure, must all be mentioned. For examination with the ftuoroscopc a room must be chosen that can be darkened at will, but the photo- graphic work can be done in any room. The hand and arm can be photographed on a table while the patient is seated on a chair. The other parts of the body may be taken while the patient lies either on a heavy wooden table or on a carpeted floor. (See Fig- 17 3-) Absolute rest is the conditio sine qua non of a dis- tinct picture. In children and in nervous adults efforts to attain perfect immobilization may fail. The trunk must be supported properly by pillows, while an ex- tremity can be kept quiet by supporting it with sand- bags. The patient should, of course, be placed as comfortably as possible, but in some individuals it is utterly impossible to take a skiagraph. Infants should be lulled into sleep, the noise of the battery, if not too strong, sometimes acting like a lullaby. Anesthesia for the purpose of keeping the patient quiet should be resorted to only under the most pressing circum- stances. To sum up, it may be said that the modus operandi in skiagraphy would be about the following: If the thigh, for instance, should be photographed (see Fig. 173), the patient is laid straight down on the floor. The limb must be denuded and placed on the top of a sensitized plate. The patient is told to be absolutely quiet, for otherwise the whole process is spoiled. The tube must be placed above, in a hori- zontal position, where it is held by an adjustable stand. The stand used by the author (Fig. 173, s) PRACTICAL USE OF RONTGEN RAYS. 3OQ permits of a wide range of adjustment in the lateral, vertical, and horizontal directions, so that the object can be irradiated from all sides. Its exact position may be verified by dropping a plumb-line from above. Now the positive wire of the coil is connected with the wire-holder of the inclined platinum disc of the tube, while the negative wire is attached to that of the concave aluminium pole. If the lever for the direct current (Fig. i 73, I) is then turned, the motor begins to run. Thereafter the handle (Fig. 173, h) of the switch of the coil is turned, and now a slight spark will pass between the anode (a) and the cathode (c). By man- ipulating the rheostat (r) the spark is increased gradu- ally until an apple-green light fills the tube, a slightly dark shadow only being noticed below the platinum disc. With the aid of the fluoroscope or of the skia- meter, it can be now ascertained whether the fluor- escence is intense enough for thorough penetration. The fluoroscope also gives a rough impression of the pathologic conditions. If all works well, the upper surface of the platinum disc shows a gray glow, while the lower surface produces a light redness. A white-red platinum disc indicates too powerful a current ; but this can be diminished by turning the rheostat backward. If, in such an event, the walls of the tube also become very hot, it is advisable to stop the current entirely for at least half a minute. (Compare p. 281.) The wires leading from the induction coil to the tube must be kept separated from one another in order to avoid shocks. When the exposure is finished, the levers are turned back in the same succession. If a static machine is used, the sliding pole-pieces 3io APPENDIX. are separated about eight inches, the large balls un- screwed from the pole-ends, and the Leyden jars re- moved. The condensers must then be screwed on, and the square platinum disc is attached to the posi- Fig. 174. — Complete comminuted intra-articular fracture of the lower end of the radius in a woman of forty years, showing lateral as well as median dis- placement of fragments (one week after the injury). The negatives of the wire numbers 193 register the plate. tive pole of the condenser. The length of the spark- gap should be regulated so as to suit the vacuum: it must be lone if the tube has a low vacuum, and be short if it has a hio-h one. The machine must be run rapidly, but never backward or with wrong poles. PRACTICAL USE OF RONTGEN RAYS. 3 1 I The plates are then put into a dark place until they are developed, which is done in the usual way, the very simple directions being obtained with the plates when purchased. The plates should be labeled. The author uses small letters and numbers made of copper wire (Fig. 1 74), which, being placed on an edge of the plate, mark the skiagram properly and perma- nently, their shades appearing on the plate. If the letter L is put at the left and R at the right margin of the plate (Fig. 175), the correct position becomes evident at a glance. Almost all the illustrations in this book were skia- graphed on Carbutt X-ray plates ; but the Cramer and Schleussner plates also give very good results. The latter are especially to be recommended for rapid exposures. If several exposures of the same object must be taken, — as, for instance, in cholelithiasis (see p. 295), — a box of the shape of a drawer must be put under- neath, the plates being inserted in place through the open side space without dislodging the object. The plates are always better than the prints, many little details becoming lost during printing. ERRORS OF SKIAGRAPHY. As mentioned on page 286, false interpretations of a skiagraphic picture may be caused by the shadows produced by thick layers of bone. In fact, they can hardly be avoided without a thorough knowledge of the normal anatomic relations of the bone that produces such shadows. As the most minute gradation of density is registered, 3 I 2 APPENDIX. the importance of being thoroughly acquainted with the anatomic relations of the bones producing the doubt- ful shadow is evident. The question, then, would be whether the supposed shadow is normal or not. On certain portions of the skeleton the muscles and ten- dons would naturally cause obscure shadows. The car- pus is especially likely to produce such errors in the skiagraph ; the tuberositas ossis multanguli majoris, the scaphoid, the hamulus ossis hamati, the os pisiforme, and the eminentiae carpi volaris radialis and ulnaris double up the thickness of the carpus, thereby causing dark shadows, which might be mistaken for foreign bodies. Similar considerations and similar cautions apply to the other diagnostic opportunities offered by the rays. If a skiagraph of the human hand, for instance, is taken, the plate will show the least light where the bones rest, while the soft tissues appear opaque. I here is also a difference of opacity according to the thick- ness of the tissues, their blood-supply, and their air- capacity. The foot, while easily skiagraphed in the direction of the dorsum toward the planta pedis, from the toes up to the upper third of the metatarsus presents an obstacle further backward in the first and third cunei- form bones and the scaphoid, so that it is necessary also to skiagraph the foot on these portions transversely by having the outer surface rest on the support. It is by this procedure only that the isolated shadows of the astragalus, the calcaneum, the os cuboideum, the scaphoid, and the fourth and fifth metatarsal bones can be distinctly outlined, so that false interpretations may be excluded. PRACTICAL USE OF RONTGEN RAYS. 31 3 In the early Rontgenian era the normal sesamoids were also sometimes incorrectly interpreted. How important is the knowledge of minute anatomic details, especially of non-pathologic abnormalities, will be evident from the fact that the os intermedium cruris (os trigonum tarsi) has been mistaken for a fragment severed from the astragalus. This bone is a typical part of the tarsus of all mammalia, and its frequency is estimated at from seven to eight per cent. Shepherd,* who mistook this bone for a fractured fragment, says: "The fact that this fracture is not mentioned in any of the text-books of surgery or in special treatises on fractures would easily be accounted for by its only being discovered by dissection ; it causes no deformity, and the symptoms it would give rise to during life would probably be obscure." The same author tried to produce this fracture artificially on the cadaver, but "in every case," he says, "where this manceuver was performed I failed, even when the greatest force was used, to break off the little process of bone mentioned above." Pfitzner-j- regards the os trigonum tarsi as an inte- gral part of the posterior process of the astragalus in the adult, which is analogous to the os intermedium antibrachii. The practical significance of this bone is evident from a case described by Wilmans, J which is also highly interesting from a medicolegal standpoint : *" A Hitherto Undescribed Fracture of the Astragalus," "Journal of Anatomy and Physiology," October, 1882. f " Beitrage zur Kenntniss des menschlichen Extremitaatenskelets," " Morphologische Arbeiten," 1896, 2 tes Heft. % " Fortschritte auf dem Gebiete der Ronlgenstrahlen," Band 11, Heft 3. 314 APPENDIX. A laborer claimed that he was injured by an iron bar on January 20, 1897, but was able to work during the whole day. On the following day he called on Dr. Wilmans, complaining of intense pain at his internal malleolus. He limped and asserted his inability to work. Wilmans found a slight swelling below the right internal malleolus. Ecchymosis of the skin be- ing absent, the swelling was attributed to the presence of a considerable degree of talipes, from which the laborer suffered at the same time. The leg was ele- vated and fomentations were applied for several days. The laborer still complaining of great pain, it was decided to transfer him to a hospital for observation. When discharged, after several weeks of treatment, the laborer made an effort to resume work, but at once declared that he was unable to keep it up. He was therefore admitted to another hospital, where he re- peated this manceuver several times during a period of six months. Finally he claimed damages for having been crippled by the injury sustained on January 20, 1897, but in view of the negative objective condition found by Dr. Wilmans, the society decided not to grant any claims. The consequence was that the laborer was transferred to the surgical division of a third hospital for further observation. There he complained that he had continuous pains below the right external mal- leolus, even while in the recumbent position. The pain increased while walking or sitting. Stepping on the right heel he also declared to be impossible. By dis- tracting his attention, however, it was noticed that he could stand well on his heel, and he would undoubtedly have been declared a malingerer, had not the Rontcren rays come to his rescue, at least temporarily. A skia- PRACTICAL USE OF RONTGEN RAYS. 3 I 5 graph showed a bone-fragment at the junction of the astragalus with the posterior surface of the calcaneum. On the strength of this skiagraphic "proof" Dr. Wil- mans, although still mistrusting, was forced to modify his original opinion, and certified that the patient suf- fered from "fracture of the astragalus, in consequence of which he was damaged for life." The laborer therefore received an annuity of thirty per cent., in proportion to the estimated curtailing of his wages. Soon afterward the laborer was discovered by Dr. Wilmans carrying a heavy weight without any apparent pain, while formerly he had claimed to be unable to walk without a cane or a crutch. Dr. Wilmans insisted upon a second irradiation, this time also skiagraphing the uninjured left foot. The skiagraph showed the " severed bone fragment," which had first been regarded as a sesamoid of the musculus flexor longus hallucis, but which was now recognized as a normal os intermedium cruris. The society, of course, refused the annuity, and the German Supreme Assurance Court, to which the laborer had appealed, not only sustained the verdict of the society, but also decided that the laborer must return the annuity which he had unjustifiably enjoyed for eighteen months. The significance of a skiagraph for the purpose of estimating the degree of functional disability, while great in general, is not always conclusive. A skia- graph may show a considerable degree of bony deformity after a fracture (compare Fig. 1 13), and still the function may hardly be disturbed at all. Skia- graphic test has shown that, as a whole, even our best functional results show by no means an ideal union, like figure 32, for instance. An unscrupulous patient 3 I 6 APPENDIX. who secures possession of a skiagraph of his own case, which shows considerable deformity, may, although there is no functional disturbance, strongly appeal to a jury on the strength of his skiagraph, if he succeeds in simulating great impairment. On the other hand, there may be but little evidence of bone-injury on the skiagraph, but there may be severe impairment of function on account of the injury to the soft tissues (circulatory, trophic, or inflammatory disturbances), which can be represented only faintly, if at all. This shows the necessity of considering all the other clinical symptoms in connection with the skiagraph. While it is easy, even for a layman, to understand the significance of most of the skiagraphs illustrated in this book, there are injuries the correct interpretation of which presupposes, besides thorough anatomic knowledge, the greatest care and a vast amount of experience as to the different modes of delineation in various projection-planes. The greatest diagnostic difficulties are offered by the joints. The more complicated a joint is, the more com- plicated the skiagraphs of its various positions will nat- urally appear. It is especially the elbow-joint and hip- joint which are kept in view. First of all, the interpreta- tion of the displacement caused by supracondylar frac- ture of the humerus, and the deformities resulting from it later on, may tax the power of discrimination consid- erably. The older the fracture, the less conspicuous the fracture-line will appear, since it will be more or less overshadowed by the callus. In old fractures the line can not be represented as such, and it is only in case of union in a displaced position that its features PRACTICAL USE OF 1«">NTGEN RAYS. 17 could be guessed. In the case illustrated by figure 1 29, for instance, a second skiagraph was taken three Fig. 175. — Congenital dislocation of both hips in a girl of seven years. The non-ossified epiphyses of the heads of the femur must not be mistaken for fracture fragments. years afterward, which showed essentially the same features as figure 129, which had been taken four 31 8 APPENDIX. weeks after the injury. (Compare also Figs. 128, 130, and 141.) In the case of entire absence of displacement it is only a very distinct skiagraph that shows the line clearly. (Compare Fig. 138.) It is natural that in such cases there is no skiagraphic evidence after recovery — that is, in from four to ten weeks, according to the type of fracture. Should a court, for instance, doubt, in such an event, that there had been a fracture, a skiagraph taken after such a period might show a negative result, although there surely was a fracture. In the case illus- trated by figure 109 the very distinct skiagraph, taken only two months after the injury, showed no signs of a fracture In the case illustrated by figure 32, where no dis- placement existed, there was only a faint fracture-line, but the presence of the callus left no doubt as to the previous existence of a fracture. (Also compare Fig. I-75-) On the other hand, callus formation may be so abun- dant (Figs. 87 and 88) that, in spite of the absence of displacement, the fullest evidence of fracture may still be furnished after months. The intra articular fracture types offer the greatest diagnostic difficulties, inasmuch as the fracture-line is also often obscured by the callus formation. (Com- pare Figs. 46 and 52.) If, however, a skiagraph of the other joint is made at the same time, in the same posi- tion, and in the same projection, the various delinea- tions of the shadows will be correctly understood and interpreted. A normal skeleton should also always be compared PRACTICAL USE OF RONTGEN RAYS. 319 on the skiagraph. It should particularly be remembered that certain pathologic conditions — such as rachitis, for instance — influence the outlines of the bones and may deceptively be supposed to represent a portion of an injury. In such an event the skiagram of the fellow-extremity will set matters right. (Compare case described on p. 314.) In very young children the eminentia capitata (Fig. 177) appears as if entirely severed from the humerus, although the relations are normal. The explanation of this important phenomenon is that the epiphyseal tissues are not sufficiently ossified to produce a shadow on the plate. If these points are not thoroughly con- sidered, a displaced fracture-fragment might be erro- neously diagnosticated. As referred to on page 74, union between the epi- physis and the diaphysis of the head of the humerus is not perfect before the twentieth year. (Compare Fig. 32.) The lower epiphysis of the humerus consists of four nuclei, which do not ossify before from the eighth to the seventeenth year. (See Figs. 176, 177.) The epiphyses of the trochlea as well as of the olecranon do not ossify before between the seventh and the twelfth years, which explains why an osseous nucleus that is still connected with its neighboring epiphyseal nuclei and the diaphysis by cartilaginous tissue appears as an isolated piece of bone which might erroneously be taken for a fragment. (Com- pare Fig. 176.) The acromioclavicular junction sometimes shows in the skiagraph a hiatus of the width of a finger, so that a diastasis of the joint might be assumed. (See Figs. 1 6 and 21.) But since our knowledge on this new sub- 320 APPENDIX. ject has increased, we know that this apparent diastasis is by no means pathologic, and that there is a normal gap between the osseous ends of the acromion and the acromial end of the clavicle. The upper epiphysis and the diaphysis of the radius (see Figs. 46, 49) unite between the seventeenth and the eighteenth year, and its lower epiphysis and dia- Fig. 176. — Elbow-joint in a boy often years, four hours after backward dis location of radius and ulna had occurred and two hours after reduction. The non- ossified connection of the lower epiphysis of the humerus appears like a fracture- line, but the relations are perfectly normal with the exception of the dark shades in the soft tissues, which represent the bloody effusions caused by the injury. physis join in the twentieth year. (Compare Figs. 76, 87.) During the early Rontgenian era the trans- lucent space above the epiphyseal cartilage in children was erroneously taken for a fracture-line. (Fig. 73.) The head of the femur unites with the diaphysis at the eighteenth or nineteenth year (compare Fig. 109), and the lower epiphysis follows after the twentieth year. (Compare Figs. 118 a and 140.) The upper epiphysis of the tibia unites with the dia- PRACTICAL USE OF RONTGEN RAYS. 32 1 physis in the twentieth or twenty-second year (Figs. 1 18 a and 140), while the lower tibial epiphysis unites with the diaphysis between the eighteenth and the nine- teenth year. (Compare Fig. 137 and Frontispiece.) As to the different periods of ossification of the pel- vis and the normal translucent spaces in children, com- pare figures 109, 113, and 175. For the thorough interpretation of skiagraphs in children, it is important to know that at birth the dia- physes of the radius, the ulna, the metacarpal bones, and the phalanges are ossified, while their epiphyses, as well as the whole carpus, are still cartilaginous. It is not before the seventh year that an osseous nucleus shows at the lower epiphysis of the ulna. Union with the diaphysis sometimes begins with the twelfth year, but, as a rule, not before the fifteenth. Even then a small epiphyseal disc remains, which does not dis- appear before the seventeenth year in the female, and not before the nineteenth year in the male. As to the osseous nucleus of the lower end of the radius, compare page 74. The osseous nuclei of the carpus show at different periods — viz., at the os capitatum, at the fourth month ; at the hamatum, at the fifth month ; while the trique- trum shows its nucleus between the second and the third year, the lunatum between the third and the fifth, the naviculare between the fifth and the seventh, the trapezium and the trapezoid between the sixth and the seventh year, and the os pisiforme between the eleventh and the fifteenth year. After five years the capitatum, hamatum, and tri- quetrum have assumed their regular shapes, while the 322 APrENDIX. others, with the exception of the pisiforme, are per- fectly developed at the twelfth year. The osseous nuclei of the epiphyses of the metacar- pal bones show at the second year, their synostosis with the diaphysis taking place between the twelfth and the seventeenth year in the female, and at the age of nineteen in the male. The epiphyseal nuclei of the phalanges are ossified between the fourth and the fifth year, their synostosis with the diaphysis taking place at the same age as that of the metacarpal bones (from the twelfth to the seventeenth year in the female, and between the sixteenth and the nineteenth year in the male). Regarding the elbow-joint, it must be considered that an osseous nucleus appears at the interior of the capitulum humeri between the second and the third year, another one in the internal epicondyle at the fifth year, a third in the trochlea between the eleventh and the twelfth year, and soon afterward a fourth in the external epicondyle. The nucleus of the internal epicondyle unites with the diaphysis between the sixteenth and the twentieth year ; but the other three nuclei form a synostosis among themselves at the seventeenth year, and then form the uniform osseous epiphysis, which completes its synostosis with the diaphysis at about the twentieth year. (Compare Figs. 176 and 177.) In the capitulum radii an osseous nucleus appears between the fifth and the seventh year, and in the olecranon between the sixth and the eighteenth year, both uniting with the diaphysis between the twentieth and the twenty-fifth and between the sixteenth and the twentieth year. PRACTICAL USE OF RONTGEN RAYS. O- J Regarding the knee-joint, it must be considered that the lower femoral epiphysis contains an osseous nucleus at birth, while the nucleus in the tibial epiphy- sis shows shortly afterward. At the fourth year both these epiphyses have completed their development, but they do not unite with the diaphysis before the fifteenth year. The anatomic text-books say that union takes place between the seventeenth and the Fig. 177. — Showing fracture of internal condyle, but normal erainentia capi- tata, the latter appearing severed from the humerus, in a boy of nine years. The perfectly normal radial epiphysis also appears severed. twenty-fourth year, but skiagraphic experience points to an average period of only sixteen. The osseous epiphyseal nucleus of the fibula appears between the second and the fifth year, and unites with the diaphysis between the eighteenth and the twenty- fifth year; but skiagraphy dates this period earlier — viz., the fifteenth year. The osseous nucleus in the tibial spine appears between the eighth and the tenth year ; the epiphyseal line disappears between it and the diaphysis at the fifteenth year. 324 APPENDIX. As to the bones of the foot, it may be said that the lower epiphyses of the tibia and the fibula show their osseous nuclei in the first and second years, and unite with the diaphysis between the eighteenth and the twenty-fifth year ; according to skiagraphs, as early as before the eighteenth year. The osseous nucleus of the astragalus and calcaneum appears intra utero, that of the cuboid shortly before or after birth, that of the cuneiformia between the first and the fifth year, and that of the os naviculare from the first to the fifth year. The osseous nuclei of the metatarsal bones and of the phalanges appear from the second to the tenth year, and unite with the diaphyses between the sixteenth and the twenty-second year. In joint fractures occurring in childhood it is neces- sary, therefore, to take at least two skiagraphs in differ- ent projection-planes and to compare them thoroughly with the normal fellow. In a case of fracture of the femoral head, for instance, the deformity had appeared three times as large as it actually was, on account of inappropriate projection. The degree of shortening of the limb was overestimated accordingly. This shows the necessity of considering the other clinical symp- toms and data in connection with the skiagraph. In fractures of childhood it should also be remem- bered that the process of ossification is influenced by various affections of the bone, as, for instance, in rickets. How important the question of projection is be- comes evident when we consider that grave errors may sometimes occur even if all the preliminary con- ditions required for a thorough understanding of the case seem to be fulfilled. This will appear from the PRACTICAL USE OF RONTGEN RAYS. 325 following experience, which has probably not been paralleled in the literature of this subject: A boy four years of age, while playing on the street, fell against an iron bar. Being unable to rise again, he was taken up and carried to St. Mark's Hospital, where in the first instance moderate pain was noted besides the functional disturbance. There was neither any difference in level or any other deformity, nor any shortening or the typical equinus position. A photo- graph taken two days after the injury only showed a very moderate and uniform swelling of the leg.* Ab- normal mobility and crepitus, in accordance, could be produced only by very rough manipulations. On the day following the injury two skiagraphs were made in different positions ; one of them (Fig. 137) in the dorsal and the other (Fig. 139, A) in the lateral position. To my surprise, figure 137 — which had been skiagraphed by a direct irradiation, the cen- ter of the platinum disc of the tube being perpendicu- lar to the anterior surface of the leg — did not show the slightest indication of a fracture, while figure 139, A (also compare Frontispiece), which represents the leg irradiated from the outer aspect of the tibia, shows a marked fracture-line. The fracture presented the typical oblique type in the middle of the tibia, the fracture-line running from below anteriorly to above posteriorly, the upper, taper- ing fragment overlapping the lower end. No sideward displacement having been present, it can be under- stood why the rays, reaching the long axis of the tibia in a vertical direction, do not show the fracture-line. * Photograph published in "New York Medical Journal," January 6, 1900. 326 APPENDIX. A very slight change in the position, where the inclina- tion toward the fibular direction amounts to less than one millimeter, brought out the fracture distinctly. Now, if I had, as is the custom in general, taken a skiagraph in the anteroposterior direction only, and if the manipulations made during the first examination were carried out as gently as they properly should be, the fracture might have been overlooked entirely. And if, in view of the local pain and tenderness, the swelling - , .and the functional disturbance, the possibility of a fracture would have been seriously considered, the skiagraph (Fig. 137) might have silenced the uneasy conscience. This experience teaches the necessity of adopting the principle of always taking at least two skiagraphs in two different positions in all cases of suspected fracture. The medicolegal aspects of a case of this kind need no further comment. In taking skiagraphs of foreign bodies it must be considered that their size varies according to the dis- tance from the tube. (Compare p. 305.) In oblong bodies great errors as to their extent may be com- mitted. The author once was very much surprised in a case where a needle-fragment had entered the palm of the hand in a perpendicular direction. The plate, while indicating the presence of the needle distinctly, created the impression that the fragment was only about two millimeters in length. When extracted it was found to be more than an inch long, the rays having reached the hand in a perpendicular direction, so that the circumference of the fragment was repro- duced rather than its length. A side view, of course, would have cleared up the error at once. PRACTICAL USE OF RONTGEN RAYS. 327 Misinterpretations have also arisen from unavoid- able mechanical and chemic defects, causing markings in the photographic plate, the significance of which must be well known to the skiagraphic interpreter. Blemishes may be produced by spots caused by pus from wounds or by perspiration. In the location of foreign bodies, especially in the skull, many errors were and are still committed. As to their avoidance, compare pages 265 and 306. In drawing conclusions from skiagraphs it should especially not be lost sight of that a skiagraph is by no means a photograph of an object, but a silhouette — that is, a photograph of its shadow. INDEX. Abdominal plaster-of-Paris dressing, 1 86 Acromegaly, 28S Acromioclavicular junction, 319 Acromion, fracture of, 90 Adhesions, 33 in fracture of lower end of radius, 142 Adhesive plaster in extension treatment, 5o Air-brake wheel, 279 Air expired by the surgeon, 54 Alternating current, 280 Alveolar process, fracture of, 271 Ambulatory dressing, 42 in fracture of femur, 187 in supramalleolar fracture, 208 Anesthesia, 37 Aneurysm, 32 of the aorta, 291 of the thigh, 289 Ankle-joint, inflammatory process in, 213 dislocation of, 214 Ankylosis, 33 of knee-joint, 190 treatment of, 72 Anode, 280 Antibrachium, backward dislocation of, 109 Antrum Highmori, osteoplastic resec- tion of, 265 Aortic aneurysm, 291 Arteriosclerosis, 292 Arthritis, simple, 288 Asepsis in compound fractures, 51 in puncturing extravasations, 198 intra-oral, in fracture of inferior maxilla, 274 Astragalus, alleged fracture of, 315 fracture of, 226 Atmospheric infection, 52 Atrophy, ^3 Axial displacement, 18 Axillary dislocation, 98 Backward dislocation of ankle-joint, 214 of forearm, 109 displacement in fracture of lower end of tibia, 222 Bactericidal influence of the RSntgen rays, 303 Base of skull, fracture of, 285 Battle-field, immobili?ation on the, 39 Beck's dressing for fracture of the clavicle, 87 operating table, 41 Bernard's, Claude, sign, 253 Bladder, paresis of, in fracture of spinal column, 241 Blemishes of photographic plates, 327 Blood-ferment, absorption of, 26 Body, scapular, fracture of, 89 Bone-suture, 70 Bony ankylosis, 33 Bracelet for fracture of lower end of radius, 143, 152 Brachial plexus in fracture of spinal column, 242 Buck's extension, 49 Bullets in the skull, 252 in the thoracic cavity, 292 Calcaneum, fracture of, 229 Calcareous areas in the lungs, 290 Calculi, biliary, 295 renal, 294 vesical, 294 Callus-formation, 27, 318 in fracture of lower end of humerus, 120 in fracture of lower end of radius, .155 Capitulum humeri, separation of, 119 Carcinoma of esophagus, skiagraphy of, 294 of pylorus, skiagraphy of, 294, Carpus, fracture of, 161 osseous nucleus of, 321 529 INDEX. Cartilages of joints, 288 Cathode, 2S0 Cathode-ray, 10 Cerebral abscess, 261 commotion, 253 compression, 254 contusion, 255 Cerebrospinal fluid, escape of, in frac- ture of base of skull, 267 Cervical vertebrae, fracture of, 241 Change of knife after skin-incision, 57 Children, fracture of skull in, 73 peculiarities of fractures in, 73 Chondro-epiphyseal separation of lower end of radius, 139 Clavicle, fracture of, 78 Classification of fractures, 17 Coaptation-splints in fracture of femur, 186 Coccygodynia, 288 Coccyx, fracture of, 30, 288 Collar-splint, 44 Colles' fracture, 145 Comminuted fracture, 19 Commotion in fracture of vertebral bodies, 241 Complete fractures, 18 Compound fractures, 1 8, 34 asepsis in, 51 of radius and ulna, 159 Compression in fracture of vertebral bodies, 241 Congenital dislocation of hip, 287 fractures, 73 Consolidation, time for, 29 Constitutional causes of non-union, 32 diseases causing fractures, 17 Contusions, differentiation in general, 24 Coracoid process, fracture of, 92 Coronoid process of ulna, fracture of, 125 ( 'ostal cartilages, fracture of, 237 Crepitus, 21 Crookes, IO Cubital process, fracture of, 1 15 Cuboid bone, fracture of, 231 Cuneiform bone, fracture of, 23 1 Current, alternating, 280 Cystitis in fracture of spinal column, 241 DECUBITUS in fracture of spinal column, 244 Defects of photographic plates, 327 Deformity, 22 Delirium tremens, 34 treatment of, 72 Dental splint, 274 Dentistry, use of Rontgen rays in, 304 Depilation caused by Rontgen rays, 301 Dermatitis caused by Rontgen rays, 300 Diacondylar fracture of lower end of humerus, 1 13 Diagnosis, 23 Diastasis in fracture of patella, 200 Direct current, 277 fractures, 17 Disability, functional, 315 Dislocation, differentiation in general, 24 of antibrachium, 109 of hip, 287 Displacement, absence of, 35 Disposition to infection, 58 Dissemination of force in fracture of skull, 249 Distance of plate from tube, 305 Distortion, differentiation between frac- ture of external malleolus and, 225 between fracture of lower end of tibia and, 220 Disturbances in process of repair, 31 of nutrition of bones, 17 Dorsal dislocation of thumb, 162 Dosage in skiagraphy, 301 Dressing, change of, 68 Dust in the operating room, 53 Dwarfs, epiphysis in, 75 ECCHYMOSIS, 23 Echinococcus, skiagraphy of, 294 Eczema treated by Rontgen rays, 301 Edema, 39 of foot, 231 Edison-Lalande cells, 277 Elbow-joint, osseous nucleus of, 322 Electric current, 277 Embolism, 32 treatment of, J I Emergency cases, treatment of, 37, 39 Eminentia capitata humeri, separation of, 119 Encephalitis in fracture of skull, 261 Enchondroma, 289 of larynx, 293 Enophthalmos in fracture of orbit, 264 Epicondylar fracture of humerus, 115 Epiphyseal separation, 73, 76 of lower end of radius, 139 INDEX. 00 U Exophthalmos in fracture of base of skull, 266 Exposure, length of time of, 305 of skin-bacteria, 57 Extension-dressings, 39 External epicondyle, fracture of, 116 malleolus, fracture of, 225 Extravasation, treatment of, 38 Facial bones, fracture of, 268 False mobility, causes of, 31 Faraday, 9 Fat-embolism, 26 Faulty position after fracture of femur, 181 Femur, epiphyseal cartilage of, 320 separation of lower end of, 190 of upper end of, 1 68 extracapsular fracture of neck of, 172 fracture of diaphysis of, 179 of lower third of, 183 of middle of, 184 of neck of, 169 of upper end of, 168 infratrochanteric fracture of, 179 intta-articular severing of a piece at the lower end of, 192 intracapsular fracture of, 170 isolated fracture of trochanter major of, 177 Fenestrated plaster-of-Paris dressing, 41 Fiber, splints made of, 48 Fibroma, 289 Fibrous ankylosis, 23 Fibula, abnormal development of, 217 isolated fracture of, 223 osseous nucleus of, 323 pseudarthrosis of, 226 simultaneous fracture of tibia and, 205 Finger, fracture of, 161 Finger-nails, cleaning of, 60 Firearms, effect of modern, 255 Fissure, 20 of lower end of radius, 139 Fixation of fragments, 35 Fixed dressings, 39 Floating bodies in knee-joint, 287 Fluorescing screen, 284 Fluoroscope, 284 Fluoroscopic examination, 308 Foot, fractures of, 226 osseous nuclei of, 324 position of, in skiagraphy, 307 Foot-board, 50 Foot-edema of soldiers, 231 Forceps, Beck's, for fastening napkins to the wound-margins, 64 Forearm, fractures of, 121 position of, in skiagraphy, 306 Foreign bodies, 286, 326 in the eye, 288 in the skull, 288 location of, 306 Forward dislocation of ankle-joint, 214 Functional disability, 22 Fusion of radius and ulna after radial fracture, 159 of radius and ulna after ulnar frac- ture, 129 Gall-bladder, skiagraphy of, 297 Gall-stones, chemic composition of, 296 skiagraphy of, 295 Gangrene, 32, 39 caused by the Rontgen rays, 300 Geissler, 10 Glands containing bacteria, 56 Glisson's cradle in fracture of spinal column, 241 Gloves during operation, 60 Gowns, sterilized, 64 Graefe's head-band, 271 Green-stick fracture in children, 76 Gunshot fracture, 19 of skull, 252 Hand, fracture of bones of, 161 position of, in skiagraphy, 307 Hands of surgeon, sterilization of, 60 Head, fracture of radial, 132 Heart, injury to, in fracture of rib, 237 skiagraphy of, 291 Hemorrhage from the ear in fracture of base of skull, 266 from pharynx in fracture of base of skull, 266 Hemothorax in fracture of rib, 235 Hertz, 9 Hip-joint, dislocation of, 287 position of, in skiagraphy, 307 Hittorf, 10 Humeroradial joint, position of, in ski- agraphy, 307 Humero-ulnar joint, position of, in ski- agraphy, 307 Humerus, appearance of nucleus in, .74 diacondylar fracture of, 1 13 INDEX. Humerus, epicondylar fracture of, 1 15 epiphyseal cartilage of, 319 fracture of anatomic neck of, 92 of diaphysis of, 105 of lower end of, 108 of surgical neck of, 94 of tuberculum majus or minus of, 104 of upper end of, 92 intercondylar fracture of, 118 supracondylar fracture of, 108 transtubercular fracture of, 103 traumatic epiphyseal separation of lower end of, 1 14 of upper end of, 101 Hydronephrosis, 294 Hydropneumothorax, 290 Hyoid bone, fracture of, 275 Hyperesthesia in fracture of the spinal column, 243 Hypertrichosis, 301 Hypertrophied pleura, 290 Hypostatic pneumonia, 42 Iliac dislocation of femur, 175 Immobilization, 38 Implantation in non-union of bones, 69 Impacted extracapsular fracture of neck of femur, 176 fracture, 19 fragment in fracture of skull, 259 Incomplete fractures, 18, 19 Indirect fractures, 18 Infantile paralysis, fragility of bones in, 75 Infected compound fracture, 65 Inferior maxilla, fracture of, 272 Inflammatory processes causing frac- tures, 17 Infraction, 19 of lower end of radius, 139 Infratrochanteric fracture, 179 Inner table, protrusion of, 251 Intercostal artery, injury to, in fracture of rib, 233 Internal epicondyle, fracture of, 1 15 Interposition of soft tissues, 31, 182 Interrupted plaster-of- Paris dressing, 45 Intracutaneous bacteria, 56, 199 Intrauterine fracture, 19, 73> 7^ Intubation in fracture of larynx, 275 Iodin tincture as a prophylactic disin- fectant, 200 Iodoform-glycerin as a tracer, 288 Ischemic symptoms in tight dressing, 43 Isolated fracture of upper end of fibula, 223 of upper end of tibia, 216 Ivory pegs in operation for non-union of bones, 69 Knee, intra-articular separation in, 192 Knee-joint, normal view of, 191 osseous nuclei of bones of, 323 position of, in skiagraphy, 307 Kriig- jorgensen rifle, 255 Kyphosis, traumatic, in fracture of vertebral bodies, 240 Laminectomy, 245 Larynx, fracture of. 275 Late callus-formation, 30 Lateral dislocation of thumb, 163 displacement, 18 Leg, epiphyseal separation of, 205 fracture of, 204 position of, in skiagraphy, 307 Lenard, 10 Lime-wood splints, 48 Line of fracture in children, 76 Local cause of non-union, 31 Localization, intracranial, of bullets, 263 Localized pain, 23 Longitudinal displacement, iS fractures, 18 Lung-abscess, skiagraphy of, 291 Lupus treated by Rontgen rays, 302 Malleolar fracture, 211 Manual examination, 24 Marbles in after-treatment of fracture of lower end of radius, 143 Massage in after-treatment, 51 Massage-treatment in extravasation, 38 Maxwell, 9 Measurement, 24 Mechanical cause of gangrene, 32 Mediastinal tumors, 290 Medullary contusion in fracture of ver- tebral bodies, 240 Meningitis in fracture of skull, 261 Meningocele, 299 Mental portion of inferior maxilla, 273 Metacarpus, epiphyseal cartilages of, 321 fracture of, 163 osseous nucleus of, 322 Metatarsal bones, fracture of, 231 INDEX. 33 O^J Mobility, abnormal, 21 Molded plaster splints, 44 Moss-board in compound fracture, 66 in fracture of inferior maxilla, 274 Multiple fracture, 19 Muscular contraction causing fracture, 18 Myelocystocele, 300 Myelomeningocele, 300 N/EVUS vasculosus treated by Ront- gen rays, 301 Nails in operations for non-union, 69 Nasal bones, fracture of, 268 Neck, radial, fracture of, 134 scapular, fracture of, 89 Necrosis, 288 of bone-ends, 30 Nelaton's tbeory in fracture of lower end of radius, 139 Nerve, compression of, 71 insult to a, 32 Neuralgia in fracture of spinal column, 243 Neurorrhaphy in laceration of radial nerve, 133 Non-reduction of fragments, 36 Non union, 69 Oblique fractures, 18 Obstetrics, value of Rontgen rays in, 2S7 Olecranon, fracture of, 122 osseous nucleus of, 322 Os intermedium cruris, 313 trigonum tarsi, 313 Osteoarthropathie hypertrophiante pneumique, 288 Osteoblastic cells, 27 Osteochondroma, 289 Osteo-epiphyseal separation of lower end of radius, 141 Osteoma, 289 Osteomyelitis, 288 of tibia, differentiation between frac- ture and, 213 Osteoplastic resection, 287 of skull, 259 Osteopsathyrosis, 17 Osteosarcoma, 102, 289 Overriding of fragments, 3 1 Pain in infantile fracture, 76 Paralysis in fracture of spinal column, 243 Paralysis in fracture of skull, 253 Parasitic skin diseases treated by Ront- gen rays, 302 Patella, fracture of, 193 comminuted, 195 compound, 204 transverse, 195 wiring of, 201 Pelvic ring, fracture of, 167 Pelvis, fracture of, 166 Pericarditis in fracture of rib, 235 Periostitis ossificans, 27 Peripheral displacement, 19 Permanent extension, 49 Phalanges, digital fracture of, 165 epiphyseal cartilages of, 321 osseous nucleus of, 322 tarsal, fracture of, 231 Photographic plate, 285 Phrenic nerve in fracture of spinal column, 247 Plaster-of- Paris bandage, making of, 40 dressing, 40, 77 disadvantages of, 47 in wound treatment, 40 removal of, 41 Pleura, hypertrophy of, 290 Pleuritis sicca in fracture of rib, 235 skiagraphy in, 289 Pneumonia, 34 in fracture of rib, 235 treatment of, 72 Pneumothorax in fracture of rib, 235 Position in skiagraphy, 306 of tube, 307 Pott's fracture, 211 Powell's electric saw, 259, 260 Preglenoid dislocation, 93, 99 Pressure of bone-fragments, 36 Projection in skiagraphy, 324 Prolonged immobilization, ^3 Pseudarthrosis in fracture of anti- brachium, 159 of femur, 189 of fibula, 226 of humerus, 107 in simultaneous fracture of radius and ulna, 156 Psoriasis treated by Rontgen rays, 301 Puncturing in extravasation, 38 Pulmonic tumors, 290 Putrid cavities, treatment of, 67 Pyelonephritis in fracture of spinal column, 241 Pyothorax, 289 14 INDEX. Rachitic deformities, 287, 324 Radial nerve, laceration of, 133, 135 embedded in callus, 135 Radius, appearance of nucleus in, 74, 322 epiphyseal cartilage of, 350, 321 extra-articular complete fracture of (Colles'), 145 fracture of, 132 and ulna together, 156 head of, 132 lower end of, 136 combined with fracture of styloid process of ulna, 154 combined with fracture of ulnar head, 153 neck of, 134 shaft of, 1 35 Rectum in fracture of spinal column, 243 Refracturing femur for deformity, 189 Registration of skiagrams, 311 Renal calculi, 294 Repair in fractures, 26 Reposition of fragments, 35 Rheostat, 280, 309 Rheumatism, 288 Rib, compound fracture of, 237 fracture of, 232 infraction of, 233 Rickets, 75 Rontgen, 9 Rubber adhesive plaster in fracture of rib, 235 Ruhmkorff induction coil, 277, 279 Salicylic acid as a mouth-wash, 274 Saline infusions, 65 Sayre's dressing for fracture of clavicle, 86 Scaphoid, fracture of, 231 Scapula, fracture of, 89 Screen, fluorescing, 284 Serothorax, skiagraphy in, 290 Scurvy, fragility of bones in, 75 Shock in fractures, 26 Shoulder, fracture of, 78 Signs of fracture, 21 Silicate-of-potassium dressing, 46 Simple fracture, iS Skiagraphic errors, 31 1 Skiagraphs, taking of, 285 Skiameter, 283 Skin-bacteria, 54 Skin-incision, danger of infection in, 57 Skull, fracture of, 247 Soap for sterilization, 55 Sodium dressing, 46 Spasms in fracture of spinal column, 243 Spina bifida, skiagraphy in, 299 Spinal column, fracture of, 239 Spine, scapular, fracture of, 89 Spinous process, vertebral, fracture of, 246 Spiral fracture, 18 infratrochanteric fracture, 179 Splinters in compound fractures, 65 removal of, in fracture of skull, 259 Splints in general, 48 of fiber, 4S of lime-wood, 48 of wire, 48 Spondylitis, 28S Spontaneous fractures, 17 Staircase-shaped exsection, 70 Stand, adjustable, for skiagraphic work, 308 Static machine, 277, 309 Statistics, 20 Stellate splinter fracture of the scapula, 90 . Sterilization, 52 of aspirating needles, 19S of syringes, 199 Sternum, fracture of, 238 Stomach, skiagraphy of, 294 Storage-battery, 277 Strabismus in fracture of base of skull, 267 Styloid process of ulna, fracture of, 1 29 Subcoracoid dislocation, 93, 99 Subcutaneous fracture, 34 suture, 58 Subglenoid dislocation, 99 Subphrenic abscess, skiagraphy of, 291 Superior maxilla, fracture of, 270 Supramalleolar fracture, 209 Suspension in a splint, 45 Swelling of soft tissues, 27 Sycosis treated by Rontgen rays, 301 Symptoms of fracture in children, 75 Syphilis, 288 Talipes, 287 Tarsal bones, fracture of, 226 gangrene of, 227 Tesla's high-tension induction coil, 277 Thigh, fracture of, 168 position of, in skiagraph}', 307 skiagraphing the, 308 INDEX. OOD Tibia, appearance of nucleus in, 74 atrophy of, 217 backward displacement in fracture of, 222 epiphyseal cartilage of, 320 error in fracture of, 219 gunshot fracture of, 217 infraction of, 219 isolated fracture of, 216 simultaneous fracture of tibia and fibula, 205 spiral fracture of, 221 Thrombosis, 32 Thumb, dorsal dislocation of, 162 Torsion, 19 Tracheotomy in fracture of the larynx, 275 Transposition of the viscera, 293 Transverse fracture, 18 Traumatic cause of gangrene, 32 Treatment in general, 34 of disturbances in the process of re- pair, 70 Trephining of spinal canal, 245 Trochanter major, isolated fracture of, 177 Trochlea, epiphyseal cartilage of, 319 Trunk, fractures of bones of, 232 Tube, capacity of, 305 distance from, 305 Tuberculosis, differentiation of, 268 of bones, fragility in, 75 Tubes, 9, 280, 305 permitting of regulation, 305 Tumors of shoulder, differentiation from fractures, 100 Tympanum, laceration of, in fracture of base of skull, 266 Ulna, epiphyseal cartilages of, 321 fracture of, 122 coronoid process of, 125 diaphysis of, 127 fissure of capitulum of, 131 isolated fracture of styloid process of, 129 Upper arm, position of, in skiagraphy, 306 Urine in fractures, 26 of spinal column, 244 Vacuum, height of the, 304 of Rontgen tube, 282 Velpeau*s dressing for fracture of clav- icle, 85 Venous stasis, 39 Vertebral bodies, fracture of, 239 infraction of, 240 Vertical extension in infantile fracture of femur, 186 Vertex, fracture of, 248 Vesical calculi, skiagraphy of, 294 Vibrator, 279 Volkmann's foot-board, 50 Wire splints, 48, 67 Wiring of bone-fragments, 51 in fracture of inferior maxilla, 273 of patella, 201 Wound-margins, protection of, 58 Zygoma, fracture of, 271 CATALOGUE OF THE MEDICAL PUBLICATIONS OF W. B* SAUNDERS, No. 925 WALNUT STREET, PHILADELPHIA* Arranged Alphabetically and Classified under Subjects. THE books advertised in this Catalogue as being sold by subscription are usually to be obtained from travelling solicitors, but they will be sent direct from the office of pub- lication (charges of shipment prepaid) upon receipt of the prices given. All the other books advertised are commonly for sale by booksellers in all parts of the United States ; but books will be sent to any address, carriage prepaid, on receipt of the published price. Money may be sent at the risk of the publisher in either of the following ways : A post- office money order, an express money order, a bank check, and in a registered letter. Money sent in any other way is at the risk of the sender. See pages 32, 33 for a List of Contents classified according to subjects. LATEST PUBLICATIONS. International Text-Book of Surgery. See page 15. American Text-Book of Surgery — Third (Revised) Edition. See page 7. American Text-Book of Dis. of Eye, Ear, Nose, and Throat. Page 5. American Text-Book of Genito-Urinary and Skin Diseases. Page 6. Saunders' American Year-Book for 1900. See page 8. Levy and Klemperer's Clinical Bacteriology. See page 17. Scudder's Treatment of Fractures. See page 26. Beck on Fractures. See page 9. Heisler's Embryology. See page 15. Nancrede's Principles of Surgery. See page 20. Jackson's Diseases of the Eye. See page 16. Kyle on the Nose and Throat. See page 17. Pryor's Pelvic Inflammations. See page 2J. Abbott's Hygiene of Transmissible Diseases. See page 8. Stengel's Text-Book of Pathology — Second Edition. See page 28. Hirst's Text-Book of Obstetrics — Second Edition. See page 15. Penrose's Diseases of Women — Third (Revised) Edition. Page 20. Warren's Surgical Pathology — Second (Revised) Edition. Page 31. Anders' Practice of Medicine — Third I Revised I Edition. See page 8. Church and Peterson's Nervous and Mental Diseases — 2d Ed. Page 10. Da Costa's Surgery — Revised and Enlarged Edition. See page 12. Saunders' Medical Hand-Atlases. See pages 2, 3, 4. De Schweinitz's Diseases of the Eye — Third (Revised) Ed. Page 12. American Pocket Medical Dictionary — Second i Revised) Ed. Page 12. SAUNDERS' MEDICAL HAND-ATLASES. The series of books included under this title consists of authorized translations into English of the world-famous Lehmann Medicinische Handatlanten, which for scientific accuracy, pictorial beauty, com- pactness, and cheapness surpass any similar volumes ever published. Each volume contains from 50 to 100 colored plates, executed by the most skilful German lithographers, besides numerous illustrations in the text. There is a full and appropriate description of each plate, and each book contains a condensed but adequate outline of the subject to which it is devoted. One of the most valuable features of these atlases is that they offer a ready and satisfactory substitute for clinical observation. To those unable to attend important clinics these books will be absolutely indis- pensable. In planning this series of books arrangements were made with the rep- resentative publishers in the chief medical centers of the world for the publication of translations of the atlases into different languages, the litho- graphic plates for all these editions being made in Germany, where work of this kind has been brought to the greatest perfection. The expense of making the plates being shared by the various publishers, the cost to each one was materially reduced. Thus by reason of their universal transla- tion and reproduction, the publishers have been enabled to secure for these atlases the best artistic and professional talent, to produce them in the most elegant style, and yet to offer them at a price heretofore unap- proached in cheapness. The success of the undertaking is demonstrated by the fact that the volumes have already appeared in thirteen different languages — German, English, French, Italian, Russian, Spanish, Japanese, Dutch, Danish, Swedish, Roumanian, Bohemian, and Hungarian. In view of the striking success of these works, Mr. Saunders has con- tracted with the publisher of the original German edition for one hun- dred thousand copies of the atlases. In consideration of this enormous undertaking, the publisher has been enabled to prepare and furnish special additional colored plates, making the series even handsomer and more complete than was originally intended. As an indication of the practical value of the atlases and of the favor with which they have been received, it should be noted that the Medical Department of the U.S. Army has adopted the "Atlas of Operative Surgery" as its standard, and has ordered the book in large quantities for distribution to the various regiments and army posts. The same careful and competent editorial supervision has been secured in the English edition as in the originals, the translations being edited by the leading American specialists in the different subjects. SAUNDERS' MEDICAL HAND-ATLASES. VOLUMES NOW READY. Atlas and Epitome of Internal Medicine and Clinical Diagnosis. By Dr. Chr. Jakob, ofErlangen. Edited by Augustus A. Eshner, M.D., Professor of Clinical Medicine, Philadelphia Polyclinic. With 68 colored plates, 64 text-illustrations, and 259 pages of text. Cloth, $3.00 net. " The charm of the book is its clearness, conciseness, and the accuracy and beauty of its illustrations. It deals with facts. It vividly illustrates those facts. It is a scientific work put together for ready reference." — Brooklyn Medical Journal. Atlas of Legal Medicine. By Dr. E. R. von Hofmann, of Vienna. Edited by Frederick Peterson, M.D., Chief of Clinic, Nervous Dept., College of Physicians and Surgeons, New York. With 120 Colored figures on 56 plates, and 193 beautiful half-tone illustrations. Cloth, $3.50 net. " Hofmann's 'Atlas of Legal Medicine ' is a unique work. This immense field finds in this book a pictorial presentation that far excels anything with which we are familiar in any other work." — Philadelphia Medical Journal. Atlas and Epitome of Diseases of the Larynx. By Dr. L. Grunwald, of Munich. Edited by Charles P. Grayson, M.D., Physician-in-Charge, Throat and Nose Department, Hospital of the University of Pennsylvania. With 107 colored figures on 44 plates, 25 text- illustrations, and 103 pages of text. Cloth, $2.50 net. " Aided as it is by magnificently executed illustrations in color, it cannot fail of being of the greatest advantage to students, general practitioners, and expert laryngologists." — St. Louis Medical and Surgical Journal. Atlas and Epitome of Operative Surgery. By Dr. O. Zuckerkandl, of Vienna. Edited by J. Chalmers DaCosta, M.D., Clinical Professor of Surgery, Jefferson Medical College, Philadelphia. With 24 colored plates, 217 text-illustrations, and 395 pages of text. Cloth, $3.00 net. " We know of no other work that combines such a wealth of beautiful illustrations with clearness and conciseness of language, that is so entirely abreast of the latest achievements, and so useful both for the beginner and for one who wishes to increase his knowledge of operative surgery." — Munchener medicinische Wochenschrift. Atlas and Epitome of Syphilis and the Venereal Diseases. By Prof. Dr. Franz Mracek, of Vienna. Edited by L. Bolton Bangs, M.D., Professor of Genito-Urinary Surgery, University and Bellevue Hospital Medical College, New York. With 71 colored plates, 16 black-and- white illustrations, and 122 pages of text. Cloth, $3.50 net. " A glance through the book is almost like actual attendance upon a famous clinic." — Journal of the American Medical Association. Atlas and Epitome of External Diseases of the Eye. By Dr. O. Haab, of Zurich. Edited by G. E. de Schweinitz, M.D., Professor of Ophthalmology, Jefferson Medical College, Philadelphia. With 76 colored illustrations on 40 plates, and 228 pages of text. Cloth, $3.00 net. " It is always difficult to represent pathological appearances in colored plates, but this work seems to have overcome these difficulties, and the plates, with one or two exceptions, are absolutely satisfactory." — Boston Medical and Surgical Journal. Atlas and Epitome of Skin Diseases. By Prof. Dr. Franz Mracek, of Vienna. Edited by Henry W. Stelwagon, M.D., Clinical Professor of Dermatology, Jefferson Medical College, Philadelphia. With 63 colored plates, 39 half-tone illustrations, and 200 pages of text. Cloth, $3.50 net. " The importance of personal inspection of cases in the study of cutaneous diseases is readily appreciated, and next to the living subjects are pictures which will show the appear- ance of the disease under consideration. Altogether the work will be found of very great value to the general practitioner." — Journal of the American Medical Association. 3 SAUNDERS' MEDICAL HAND-ATLASES. IN PRESS FOR EARLY PUBLICATION. Atlas and Epitome of Diseases Caused by Accidents. By Dr. Ed. Golebiewski, of Berlin. Translated and edited with additions by Pearce Bailey, M.D., Attending Physician to the Department of Cor- rections and to the Almshouse and Incurable Hospitals, New York. With 40 colored plates, 143 text-illustrations, and 600 pages of text. Atlas and Epitome of Special Pathological Histology. By Dr. H. Durck, of Munich. Edited by Ludvig Hektoen, M.D., Professor of Pathology, Rush Medical College, Chicago. Two volumes, with about 120 colored plates, numerous text-illustrations, and copious text. Atlas and Epitome of General Pathological Histology. With an Appendix on Pathohistological Technic. By Dr. H. Durck, of Munich. Edited by Ludvig Hektoen, M.D., Professor of Path- ology, Rush Medical College, Chicago. With 80 colored plates, numerous text-illustrations, and copious text. Atlas and Epitome of Gynecology. By Dr. O. Schaffer, of Heidel- berg. Edited by Richard C. Norris, A.M., M.D., Gynecologist to the Methodist Episcopal and the Philadelphia Hospitals ; Surgeon-in- Charge of Preston Retreat, Philadelphia. With 90 colored plates, 65 text-illustrations, and 308 pages of text. IN PREPARATION. Atlas and Epitome of Orthopedic Surgery. By Dr. Schultess and Dr. Luning, of Zurich, With about 100 colored illustrations. Atlas and Epitome of Operative Gynecology. By Dr. O. Schaffer, of Heidelberg. With 40 colored plates and numerous illustrations in black-and-white from original paintings. Atlas and Epitome of Diseases of the Ear. Edited by Prof. Dr. Politzer, of Vienna, and Dr. G. Bruhl, of Berlin. With 120 colored illustrations and about 200 pages of text. Atlas and Epitome of General Surgery. Edited by Dr. Marwedel, with the cooperation of Prof. Dr. Czerny. With about 200 colored illustrations. Atlas and Epitome of Psychiatry. By Dr. Wilh. Weygandt, of Wiirzburg. With about 120 colored illustrations. Atlas and Epitome of Normal Histology. By Dr. Johannes Sobotta, of Wiirzburg. With 80 colored plates and numerous illustrations in the text. Atlas and Epitome of Topographical Anatomy. By Prof. Dr. Schultzf, of Wiirzburg. With about 100 colored illustrations and a very copious text. THE AMERICAN TEXT-BOOK SERIES. AN AMERICAN TEXT=BOOK OF APPLIED THERAPEUTICS. By 43 Distinguished Practitioners and Teachers. Edited by James C. Wilson, M.D., Professor of the Practice of Medicine and of Clinical Medicine in the Jefferson Medical College, Philadelphia. One hand- some imperial octavo volume of 1326 pages. Illustrated. Cloth, #7.00 net; Sheep or Half Morocco, $8.00 net. Sold by Subscription. " As a work either for study or reference it will be of great value to the practitioner, as it is virtually an exposition of such clinical therapeutics as experience has taught to be of the most value. Taking it all in all, no recent publication on therapeutics can be compared with this one in practical value to the working physician." — Chicago Clinical Review. "The whole field of medicine has been well covered. The work is thoroughly prac- tical, and while it is intended for practitioners and students, it is a better book for the general practitioner than for the student. The young practitioner especially will find it extremely suggestive and helpful." — The Indian Lancet. AN AMERICAN TEXT=BOOK OF THE DISEASES OF CHILDREN. Second Edition, Revised. By 65 Eminent Contributors. Edited by Louis Starr. M. D., Con- sulting Pediatrist to the Maternity Hospital, etc. ; assisted by Thomp- son S. Westcott, M. D., Attending Physician to the Dispensary for Diseases of Children, Hospital of the University of Pennsyl- vania. In one handsome imperial octavo volume of 1244 pages, profusely illustrated. Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. Sold by Subscription. "This is far and away the best text-book on children's diseases ever published in the English language, and is certainly the one which is best adapted to American readers. We congratulate the editor upon the result of his work, and heartily commend it to the attention of every student and practitioner." — American Journal of the Medical Sciences. AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, NOSE, AND THROAT. By 58 Prominent Specialists. Edited by G. E. de Schweinitz, M.D , Professor of Ophthalmology in the Jefferson Medical College, Phila- delphia ; and B. Alexander Randall, M.D., Professor of Diseases of the Ear in the University of Pennsylvania. Imperial octavo, 1251 pages; 766 illustrations, 59 of them in colors. Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. Sold by Subscription. Illustrated Catalogue of the "American Text-Books" sent free upon application. 6 Medical Publications of W. B. Saunders. AN AMERICAN TEXT=BOOK OF GENITOURINARY AND SKIN DISEASES. By 47 Eminent Specialists and Teachers. Edited by L. Bolton Bangs, M. D., Professor of Genito- Urinary Surgery, University and Bellevue Hospital Medical College, New York ; and W. A. Hard- away, M. D., Professor of Diseases of the Skin, Missouri Medical College. Imperial octavo volume of 1229 pages, with 300 engravings and 20 full-page colored plates. Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. Sold by Subscription. " This volume is one of the best yet issued of the publisher's series of ' American Text- Books.' The list of contributors represents an extraordinary array of talent and extended experience. The book will easily take the place in comprehensiveness and value of the half dozen or more costly works on these subjects which have heretofore been necessary to a well-equipped library." — New York Polyclinic. AN AMERICAN TEXT=BOOK OF GYNECOLOGY, MEDICAL AND SURGICAL. Second Edition, Revised. By 10 of the Leading Gynecologists of America. Edited by J. M. Baldy, M. D., Professor of Gynecology in the Philadelphia Polyclinic, etc. Handsome imperial octavo volume of 718 pages, with 341 illus- trations in the text, and 38 colored and half-tone plates. Cloth, $6.00 net; Sheep or Half Morocco, $7.00 net. Sold by Subscription. " It is practical from beginning to end. Its descriptions of conditions, its recommen- dations for treatment, and above all the necessary technique of different operations, are clearly and admirably presented. . . . It is well up to the most advanced views of the day, and embodies all the essential points of advanced American gynecology. It is destined to make and hold a place in gynecological literature which will be peculiarly its own." — Medical Record, New York. AN AMERICAN TEXT-BOOK OF LEGAL MEDICINE AND TOXI- COLOGY. Edited by Frederick Peterson, M.D., Clinical Professor of Mental Diseases in the Woman's Medical College, New York; Chief of Clinic, Nervous Department, College of Physicians and Surgeons, New York ; and Walter S. Haines, M.D., Professor of Chemistry, Pharmacy, and Toxicology in Rush Medical College, Chicago. In Preparation. AN AMERICAN TEXT=BOOK OF OBSTETRICS. By 15 Eminent American Obstetricians. Edited by Richard C. Nor- ris, M.D.; Art Editor, Robert L. Dickinson, M.D. One handsome imperial octavo volume of 1014 pages, with nearly 900 beautiful colored and half-tone illustrations. Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. Sold by Subscription. " Permit me to say that your American Text-Book of Obstetrics is the most magnificent medical work that I have ever seen. I congratulate you and thank you for this superb work, which alone is sufficient to place you first in the ranks of medical publishers." — Alexander J. C. Skene, Professor of Gynecology in the Long Island College Hospital, Brooklyn, N. Y. " This is the most sumptuously illustrated work on midwifery that has yet appeared. la the number, the excellence, and the beauty of production of the illustrations it far surpasses every other book upon the subject. This feature alone makes it a work which no medical library should omit to purchase." — British Medical Journal. " A& an authority, as a book of reference, as a ' working book ' for the student or prac- titioner, we commend it because we believe there is no better." — American Journal of the Medical Sciences. Illustrated Catalogue of the "American Text-Books " sent free upon application. Medical Publications of W. B. Saunders. AN AMERICAN TEXT=BOOK OF PATHOLOGY. Edited by Ludvig Hektoen, M. D.. Professor of General Pathology and of Morbid Anatomy in the University of Pennsylvania; and David Riesman, M. D., Demonstrator of Pathological Histology in the University of Pennsylvania. In preparation. AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. By 10 of the Leading Physiologists of America. Edited by William H. Howell, Ph.D., M.D., Professor of Physiology in the Johns Hop- kins University, Baltimore, Md. One handsome imperial octavo volume of 1052 pages. Illustrated. Cloth, $6.00 net ; Sheep or Half Morocco, $7. 00 net. Sold by Subscription. " We can commend it most heartily, not only to all students of physiology, but to every physician and pathologist, as a valuable and comprehensive work of reference, written by men who are of eminent authority in their own special subjects." — London Lancet. " To the practitioner of medicine and to the advanced student this volume constitutes, we believe, the best exposition of the present status of the science of physiology in the English language." — American Journal of the Medical Sciences. AN AMERICAN TEXT=BOOK OF SURGERY. Third Edition. By n Eminent Professors of Surgery. Edited by William W. Keen, M.D., LL.D., and J. William White, M.D., Ph.D. Handsome im- perial octavo volume of 1230 pages, with 496 wood-cuts in the text, and 37 colored and half-tone plates. Thoroughly revised and enlarged, with a section devoted to " The Use of the Rontgen Rays in Surgery." Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. «' Personally, I should not mind it being called THE Text-Book (instead of A Text- Book), for I know of no single volume which contains so readable and complete an account of the science and art of Surgery as this does." — Edmund Owen, F.R.C.S., Member of the Board of Examiners of the Royat College of Surgeons, England. " If this text-book is a fair reflex of the present position of American surgery, we must admit it is of a very high order of merit, and that English surgeons will have to look very carefully to their laurels if they are to preserve a position in the van of surgical practice." — London Lancet. AN AMERICAN TEXT=BOOK OF THE THEORY AND PRACTICE OF MEDICINE. By 12 Distinguished American Practitioners. Edited by William Pepper, M.D., LL.D., Professor of the Theory and Practice of Medi- cine and of Clinical Medicine in the University of Pennsylvania. Two handsome imperial octavo volumes of about 1000 pages each. Illus- trated. Prices per volume : Cloth, $5.00 net ; Sheep or Half Morocco, $6.00 net. Sold by Subscription. " I am quite sure it will commend itself both to practitioners and students of medicine, and become one of our most popular text-books." — Alfred Loomis, M.D., LL.D., Pro- fessor of Pathology and Practice of Medicine, University of the City of New York. " We reviewed the first volume of this work, and said : ' It is undoubtedly one of the best text-books on the practice of medicine which we possess.' A consideration of the second and last volume leads us to modify that verdict and to say that the completed work is in our opinion the best of its kind it has ever been our fortune to see." — New York Medical Journal. Illustrated Catalogue of the " American Text-Books" sent free upon application. 8 Medical Publications of W. B. Saunders. AN AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY. A Yearly Digest of Scientific Progress and Authoritative Opinion in all branches of Medicine and Surgery, drawn from journals, monographs, and text-books of the leading American and Foreign authors and investigators. Arranged with critical editorial comments, by eminent American specialists, under the general editorial charge of George M. Gould, M.D. Volumes for 1896,' '97, '98, and '99. One imperial octavo volume of about 1200 pages. Cloth, $6.50 net ; Half Morocco, $7.50 net. Year-Book of 1900 in two volumes — Vol. I., including General Medicine; Vol. II., General Surgery. Prices per volume: Cloth, $3.00 net; Half Morocco, $3.75 net. Sold by Subscription. " It is difficult to know which to admire most — the research and industry of the distin- guished band of experts whom Dr. Gould has enlisted in the service of the Year- Book, or the wealth and abundance of the contributions to every department of science that have been deemed worthy of analysis. ... It is much more than a mere compilation of abstracts, for, as each section is entrusted to experienced and able contributors, the reader has the advant- age of certain critical commentaries and expositions . . . proceeding from writers fully qualified to perform these tasks. ... It is emphatically a book which should find a place in every medical library, and is in several respects more useful than the famous ' Jahrbiicher' of Germany." — London Lancet. ABBOTT ON TRANSMISSIBLE DISEASES. The Hygiene of Transmissible Diseases ; their Causation, Modes of Dissemination, and Methods of Prevention. By A. C. Abbott, M.D., Professor of Hygiene and Bacteriology, University of Pennsylvania ; Director of the Laboratory of Hygiene. Octavo volume of 311 pages, containing a number of charts and maps, and numerous illustrations. Cloth, $2.00 net. THE AMERICAN POCKET MEDICAL DICTIONARY. [See D or I and' s Pocket Dictionary, page 12. J ANDERS' PRACTICE OF MEDICINE. Third Revised Edition. A Text-Book of the Practice of Medicine. By James M. Anders, M.D., Ph.D., LL.D., Professor of the Practice of Medicine and of Clinical Medicine, Medico-Chirurgical College, Philadelphia. In one handsome octavo volume of 1292 pages, fully illustrated. Cloth, #5.50 net; Sheep or Half Morocco, $6.50 net. " It is an excellent book, — concise, comprehensive, thorough, and up to date. It is a credit to you ; but, more than that, it is a credit to the profession of Philadelphia — to us." James C. Wilson, Professor of the Practice of Medicine and Clinical Medicine, Jefferson Medical College, Philadelphia. ASHTON'S OBSTETRICS. Fourth Edition, Revised. Essentials of Obstetrics. By W. Easterly Ashton, M.D., Pro. fessor of Gynecology in the Medico-Chirurgical College, Philadelphia. Crown octavo, 252 pages ; 75 illustrations. Cloth, $1. 00; interleaved for notes, $1.25. [See Saunders' Question- Com/ends, page 23.] " Embodies the whole subject in a nutshell. We cordially recommend it to our read- ers." — Chicago Medical Times. Medical Publications of W. B. Saunders. 9 BALL'S BACTERIOLOGY. Third Edition, Revised. Essentials of Bacteriology ; a Concise and Systematic Introduction to the Study of Micro-organisms. By M. V. Ball, M.D., Bacteriol- ogist to St. Agnes' Hospital, Philadelphia, etc. Crown octavo, 218 pages; 82 illustrations, some in colors, and 5 plates. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question- Compends, page 23.] " The student or practitioner can readily obtain a knowledge of the subject from a perusal of this book. The illustrations are clear and satisfactory." — Medical Record, New York. BASTIN'S BOTANY. Laboratory Exercises in Botany. By Edson S. Bastin, M.A., late Professor of Materia Medica and Botany, Philadelphia College of Pharmacy. Octavo volume of 536 pages, with 87 plates. Cloth, $2.50. "It is unquestionably the best text-book on the subject that has yet appeared. The work is eminently a practical one. We regard the issuance of this book as an important event in the history of pharmaceutical teaching in this country, and predict for it an unquali- fied success." — Alumni Report to the Philadelphia College of Pharmacy. BECK ON FRACTURES. Fractures. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and' the New York German Poliklinik, etc. 225 pages, 170 illustrations. Cloth, $ net. BECK'S SURGICAL ASEPSIS. A Manual of Surgical Asepsis. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and the New York German Poliklinik, etc. 306 pages; 65 text-illustrations, and 1 2 full-page plates. Cloth, $ 1.2 5 net. " An excellent exposition of the ' very latest ' in the treatment of wounds as practised by leading German and American surgeons." — Birmingham (Eng.) Medical Review. " This little volume can be recommended to any who are desirous of learning the details of asepsis in surgery, for it will serve as a trustworthy guide." — London Lancet. BOISLINIERE'S OBSTETRIC ACCIDENTS, EMERGENCIES, AND OPERATIONS. Obstetric Accidents, Emergencies, and Operations. By L. Ch. Boisliniere, M.D., late Emeritus Professor of Obstetrics, St. Louis Medical College. 381 pages, handsomely illustrated. Cloth, $2.00 net. " A manual so useful to the student or the general practitioner has not been brought to our notice in a long time. The field embraced in the title is covered in a terse, interesting way." — Yale Medical Journal. BROCKWAY'S MEDICAL PHYSICS. Second Edition, Revised. Essentials of Medical Physics. By Fred J. Brockway, M.D., Assistant Demonstrator of Anatomy in the College of Physicians and Surgeons, New York. Crown octavo, 330 pages; 155 fine illustrations. Cloth, $1.00 net ; interleaved for notes, $1.25 net. [See Saunders'' Question- Compends, page 23.] "We know of no manual that affords the medical student a better or more concise exposition of physics, and the book may be commended as a most satisfactory presentation of those essentials that are requisite in a course in medicine." — New York Medical Journal. 10 Medical Publications of W. B. Saunders. BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR- MACOLOGY. Third Edition, Revised. A Text=Book of Materia Medica, Therapeutics, and Pharma- cology. By George F. Butler, Ph.G., M.D., Professor of Materia Medica and of Clinical Medicine in the College of Physicians and Surgeons, Chicago; Professor of Materia Medica and Therapeutics, Northwestern University, Woman's Medical School, etc. Octavo, 874 pages, illustrated. Cloth, $4.00 net; Sheep, $5.00 net. " Taken as a whole, the book may fairly be considered as one of the most satisfactory of any single-volume works on materia medica in the market," — Journal of the American Medical Association. CERNA ON THE NEWER REMEDIES. Second Edition, Revised. Notes on the Newer Remedies, their Therapeutic Applications and Modes of Administration. By David Cerna, M.D., Ph.D., formerly Demonstrator of and Lecture-r on Experimental Therapeutics in the University of Pennsylvania ; Demonstrator of Physiology in the Medical Department of the University of Texas. Rewritten and greatly enlarged. Post-octavo, 253 pages. Cloth, #1.25. " The appearance of this new edition of Dr. Cerna's very valuable work shows that it is properly appreciated. The book ought to be in the possession of every practising physi- cian." — -New York Medical Journal. CHAPIN ON INSANITY. A Compendium of Insanity. By John B. Chapin, M.D., LL.D., Physician-in-Chief, Pennsylvania Hospital for the Insane ; late Physi- cian-Superintendent of the Willard State Hospital, New York ; Hon- orary Member of the Medico-Psychological Society of Great Britain, of the Society of Mental Medicine of Belgium. i2ino, 234 pages, illustrated. Cloth, $1.25 net. " The practical parts of Dr. Chapin's book are what constitute its distinctive merit. We desire especially to call attention to the fact that on the subject of therapeutics of insanity the work is exceedingly valuable. It is not a made book, but a genuine condensed thesis, which has all the value of ripe opinion and all the charm of a vigorous and natural style." — Philadelphia Medical Journal. CHAPMAN'S MEDICAL JURISPRUDENCE AND TOXICOLOGY. Second Edition, Revised. Medical Jurisprudence and Toxicology. By Henry C. Chapman, M.D., Professor of Institutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Philadelphia. 254 pages, with 55 illustrations and 3 full-page plates in colors. Cloth, $1.50 net. "The best book of its class for the undergraduate that we know of." — New York Medical Times. CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. Second Edition. ~ Nervous and Mental Diseases. By Archibald Church, M. D., Professor of Clinical Neurology, Mental Diseases, and Medical Juris- prudence in the Northwestern University Medical School, Chicago ; and Frederick Peterson, M. D., Clinical Professor of Mental Dis- eases, Woman's Medical College, N. Y. ; Chief of Clinic, Nervous Dept., College of Physicians and Surgeons, N. Y. Handsome octavo volume of 843 pages, profusely illustrated. Cloth, #5.00 net; Half Morocco, $6.00 net. Medical Publications of W. B. Saunders. H CLARKSON'S HISTOLOGY. A Text=Book of Histology, Descriptive and Practical. By Arthur Clarkson, M.B., CM. Edin., formerly Demonstrator of Physiology in the Owen's College, Manchester; late Demonstrator of Physiology in Yorkshire College, Leeds. Large octavo, 554 pages; 22 engravings in the text, and 174 beautifully colored original illustra- tions. Cloth, strongly bound, $4.00 net. " The work must be considered a valuable addition to the list of available text- books, and is to be highly recommended." — New York Medical Journal. "This is one of the best works for students we have ever noticed. We predict that the book will attain a well-deserved popularity among our students." — Chicago Medical Recorder. CLIMATOLOGY. Transactions of the Eighth Annual Meeting of the American Climatological Association, held in Washington, September 22-25, 1891. Forming a handsome octavo volume of 276 pages, uniform with remainder of series. (A limited quantity only.) Cloth, $1.50. COHEN AND ESHNER'S DIAGNOSIS. Second Edition, Revised. Essentials of Diagnosis. By Solomon Solis-Cohen, M.D., Pro- fessor of Clinical Medicine and Applied Therapeutics in the Philadel- phia Polyclinic ; and Augustus A. Eshner, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic. Post-octavo, 417 pages; 55 illustrations. Cloth, $1.00 net. [See Saunders' Question- Compends, page 23.] " We can heartily commend the book to all those who contemplate purchasing a 'com- pend.' It is modern and complete, and will give more satisfaction than many other works which are perhaps too prolix as well as behind the times." — Medical Review, St. Louis. CORWIN'S PHYSICAL DIAGNOSIS. Third Edition, Revised. Essentials of Physical Diagnosis of the Thorax. By Arthur M. Corwin, A.M., M.D., Demonstrator of Physical Diagnosis in Rush Medical College, Chicago ; Attending Physician to Central Free Dis- pensary, Department of Rhinology, Laryngology, and Diseases of the Chest, Chicago. 219 pages, illustrated. Cloth, flexible covers, $1.25 net. " It is excellent. The student who shall use it as his guide to the careful study of physical exploration upon normal and abnormal subjects can scarcely fail to acquire a good working knowledge of the subject." — Philadelphia Polyclinic. "A most excellent little work. It brightens the memory of the differential diagnostic signs, and it arranges orderly and in sequence the various objective phenomena to logical solution of a careful diagnosis. ' ' — Journal oj Nervous and Mental Diseases. CRAGIN'S GYNAECOLOGY. Fourth Edition, Revised. Essentials of Gynaecology. By Edwin B. Cragin, M. D., Lecturer in Obstetrics, College of Physicians and Surgeons, New York. Crown octavo, 200 pages; 62 illustrations. Cloth, $1.00 ; interleaved for notes, $1-25- [See Saunders' Question- Compends, page 23. J " A handy volume, and a distinct improvement on students' compends in general. No author who was not himself a practical gynecologist could have consulted the student's needs so thoroughly as Dr. Cragin has done." — Medical Record, New York. 12 Medical Publications of W. B. Saunders. CROOKSHANK'S BACTERIOLOGY. Fourth Edition, Revised. A Text=Book of Bacteriology. By Edgar M. Crookshank, M.B., Professor of Comparative Pathology and Bacteriology, King's College, London. Octavo volume of 700 pages, with 273 engravings and 22 original colored plates. Cloth, $6.50 net; Half Morocco, $7.50 net. " To the student who wishes to obtain a good resume of what has been done in bacteri- ology, or who wishes an accurate account of the various methods of research, the book may be recommended with confidence that he will find there what he requires." — London Lancet. Da COSTA'S SURGERY. Second Ed., Revised and Greatly Enlarged. Modern Surgery, General and Operative. By John Chalmers DaCosta, M.D., Clinical Professor of Surgery, Jefferson Medical College, Philadelphia ; Surgeon to the Philadelphia Hospital, etc. Handsome octavo volume of 900 pages, profusely illustrated. Cloth, $4.00 net; Half Morocco, $5.00 net. "We know of no small work on surgery in the English language which so well fulfils the requirements of the modern student." — Medico-Chirurgical Journal, Bristol, England. DE SCHWEINITZ ON DISEASES OF THE EYE. Third Edition, Revised. Diseases of the Eye. A Handbook of Ophthalmic Practice. By G. E. de Schweinitz, M.D., Professor of Ophthalmology in the Jefferson Medical College, Philadelphia, etc. Handsome royal octavo volume of 696 pages, with 256 fine illustrations and 2 chromo-litho- graphic plates. Cloth, $4.00 net ; Sheep or Half Morocco, $5.00 net. " A clearly written, comprehensive manual. One which we can commend to students as a reliable text-book, written with an evident knowledge of the wants of those entering upon the study of this special branch of medical science." — British Aledical Journal. " A work that will meet the requirements not only of the specialist, but of the general practitioner in a rare degree. I am satisfied that unusual success awaits it." — William Pepper, M.D., Professor of the Theory and Practice of Medicine and Clinical Medicine, University of Pennsylvania. DORLAND'S DICTIONARY. Second Edition, Revised. The American Pocket Medical Dictionary. Containing the Pro- nunciation and Definition of all the principal words and phrases, and a large number of useful tables. Edited by W. A. Newman Dorland, M. D., Assistant Demonstrator of Obstetrics, University of Pennsylvania; Fellow of the American Academy of Medicine. 518 pages ; handsomely bound in full leather, limp, with gilt edges and patent index. Price, $1.00 net; with thumb index, $1.25 net. DORLAND'S OBSTETRICS. A Manual of Obstetrics. By W. A. Newman Dorland, M.D., Assistant Demonstrator of Obstetrics, University of Pennsylvania; Instructor in Gynecology in the Philadelphia Polyclinic. 760 pages; 163 illustrations in the text, and 6 full-page plates. Cloth, $2.50 net. " By far the best book on this subject that has ever come to our notice." — American Medical Review. " It has rarely been our duty to review a book which has given us more pleasure in its perusal and more satisfaction in its criticism. It is a veritable encyclopedia of knowledge, a gold mine of practical, concise thoughts." — American Medico-Surgical Bulletin. Medical Publications of W. B. Saunders. 13 FROTHINGHAM'S GUIDE FOR THE BACTERIOLOGIST. Laboratory Guide for the Bacteriologist. By Langdon Froth- ingham, M.D.V. , Assistant in Bacteriology and Veterinary Science, Sheffield Scientific School, Yale University. Illustrated. Cloth, 75 cts. " It is a convenient and useful little work, and will more than repay the outlay neces- sary for its purchas-e in the saving of time which would otherwise be consumed in looking up the various points of technique so clearly and concisely laid down in its pages." — Ameri- can Medico- Surgical Bulletin. GARRIGUES' DISEASES OF WOMEN. Third Edition, Revised. Diseases of Women. By Henry J. Garrigues, A.M., M.D., Pro- fessor of Gynecology in the New York School of Clinical Medicine ; Gynecologist to St. Mark's Hospital and to the German Dispensary, New York City, etc. Handsome octavo volume of 756 pages, illus- trated by 367 engravings and colored plates. Cloth, $4.00 net; Sheep or Half Morocco, $5.0*0 net. " One of the best text-books for students and practitioners which has been published in the English language ; it is condensed, clear, and comprehensive. The profound learning and great clinical experience of the distinguished author find expression in this book in a most attractive and instructive form. Young practitioners to whom experienced consultants may not be available will find in this book invaluable counsel and help." — Thad. A. Reamy, M.D., LL. D., Professor of Clinical Gynecology, Medical College of Ohio. GLEASON'S DISEASES OF THE EAR. Second Edition, Revised. Essentials of Diseases of the Ear. By E. B. Gleason, S.B., M. D., Clinical Professor of Otology, Medico-Chirurgical College, Philadelphia ; Surgeon-in-Charge of the Nose, Throat, and Ear Depart- ment of the Northern Dispensary, Philadelphia. 208 pages, with 114 illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question- Compends, page 23.] " It is just the book to put into the hands of a student, and cannot fail to give him a useful introduction to ear-affections ; while the style of question and answer which is adopted throughout the book is, we believe, the best method of impressing facts permanently on the mind. ' ' — Liverpool Medico- Chirurgical Journal. GOULD AND PYLE'S CURIOSITIES OF MEDICINE. Anomalies and Curiosities of Medicine. By George M. Gould, M.D., and Walter L. Pyle, M.D. An encyclopedic collection of rare and extraordinary cases and of the most striking instances of abnormality in all branches of Medicine and Surgery, derived from an exhaustive research of medical literature from its origin to the present day, abstracted, classified, annotated, and indexed. Handsome im- perial octavo volume of 968 pages, with 295 engravings in the text, and 12 full-page plates. POPULAR EDITION : Cloth, $3.00 net .• Half Morocco, $4.00 net. " One of the most valuable contributions ever made to medical literature. It is, so far as we know, absolutely unique, and every page is as fascinating as a novel. Not alone for the medical profession has this volume value : it will serve as a book of reference for all who are interested in general scientific, sociologic, or medico-legal topics." — Brooklyn Medical Journal. "This is certainly a most remarkable and interesting volume. It stands alone among medical literature, an anomaly on anomalies, in that there is nothing like it elsewhere in medical literature. It is a book full of revelations from its first to its last page, and cannot but interest and sometimes almost horrify its readers." — American Medico- Surgical Bulletin. 14 Medical Publications of W. B. Saunders. GRAFSTROM'S MECHANOTHERAPY. A Text=Book of Mechanotherapy (Massage and Medical Gym= nasties). By Axel V. Grafstrom, B. Sc, M. D., late Lieutenant in the Royal Swedish Army ; late House Physician City Hospital, Black- well's Island, New York. i2mo, 139 pages, illustrated. Cloth, $1.00 net. GRIFFITH ON THE BABY. Second Edition, Revised. The Care of the Baby. By J- P- Crozer Griffith, M.D., Clini- cal Professor of Diseases of Children, University of Pennsylvania ; Physician to the Children's Hospital, Philadelphia, etc. 121110, 404 pages, with 67 illustrations in the text, and 5 plates. Cloth, #1.50. " The best book for the use of the young mother with which we are acquainted. . . . There are very few general practitioners who could not read the book through with advan- tage." — Archives of Pediatrics. "The whole book is characterized by rare good sense, and is evidently written by a master hand. It can be read with benefit not only by mothers but by medical students and by any practitioners who have not had large opportunities for observing children." — Ameri- can Journal of Obstetrics. GRIFFITH'S WEIGHT CHART. Infant's Weight Chart. Designed by J. P. Crozer Griffith, M. D. , Clinical Professor of Diseases of Children in the University of Penn- sylvania, etc. 25 charts in each pad. Per pad, 50 cents net. GROSS, SAMUEL D., AUTOBIOGRAPHY OF. Autobiography of Samuel D. Gross, M. D., Emeritus Professor of Surgery in the Jefferson Medical College, Philadelphia, with Remi- niscences of His Times and Contemporaries. Edited by his Sons, Samuel W. Gross, M.D., LL. D., and A. Haller Gross, A.M. Pre- ceded by a Memoir of Dr. Gross, by the late Austin Flint, M.D. Two handsome volumes, over 400 pages each, demy octavo, gilt tops, with Frontispiece on steel. Price per volume, $2.50 net. HAMPTON'S NURSING. Second Edition, Revised and Enlarged. Nursing: Its Principles and Practice. By Isabel Adams Hamp- ton, Graduate of the New York Training School for Nurses attached to Bellevue Hospital ; late Superintendent of Nurses and Principal of the Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md. 12 mo, 512 pages, illustrated. Cloth, $2.00 net. " Seldom have we perused a book upon the subject that has given us so much pleasure as the one before us. We would strongly urge upon the members of our own profession the need of a book like this, for it will enable each of us to become a training school in him- self." — Ontario Medical Journal. HARE'S PHYSIOLOGY. Fourth Edition, Revised. Essentials of Physiology. By H. A. Hare, M.D., Professor of Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia. Crown octavo, 239 pages. Cloth, #1.00 net; inter- leaved for notes, #1.25 net. [See Saunders'' Question- Compends, page 23.] "The best condensation of physiological knowledge we have yet seen." — Medical Record, New York. Medical Publications of W. B. Saunders. 15 HART'S DIET IN SICKNESS AND IN HEALTH. Diet in Sickness and in Health. By Mrs. Ernest Hart, formerly Student of the Faculty of Medicine of Paris and of the London School of Medicine for Women ; with an Introduction by Sir Henry Thompson, F.R.C.S., M.D., London. 220 pages. Cloth, $1.50. " We recommend it cordially to the attention of all practitioners ; both to them and to their patients it may be of the greatest service." — New York Medical Journal. HAYNES' ANATOMY. A Manual of Anatomy. By Irving S. Haynes, M.D., Adjunct Professor of Anatomy and Demonstrator of Anatomy, Medical Depart- ment of the New York University, etc. 680 pages, illustrated with 42 diagrams in the text, and 134 full-page half-tone illustrations from original photographs of the author's dissections. Cloth, $2.50 net. " This book is the work of a practical instructor — one who knows by experience the requirements of the average student, and is able to meet these requirements in a very satis- factory way. The book is one that can be commended." — Medical Record, New York. HEISLER'S EMBRYOLOGY. A Text=Book of Embryology. By John C. Heisler, M.D., Pro- fessor of Anatomy in the Medico- Chirurgical College, Philadelphia. Oc- tavo volume of 405 pages, handsomely illustrated. Cloth, $2.50 net. HIRST'S OBSTETRICS. Second Edition. A Text=Book of Obstetrics. By Barton Cooke Hirst, M. D., Professor of Obstetrics in the University of Pennsylvania. Handsome octavo volume of 848 pages, with 618 illustrations, and 7 colored plates. Cloth, $5.00 net; Sheep or Half Morocco, $6.00 net. "The illustrations are numerous and are works of art, many of them appearing for the first time. The arrangement of the subject-matter, the foot-notes, and index are beyond criticism. As a true model of what a modern text-book on obstetrics should be, we feel justified in affirming that Dr. Hirst's book is without a rival." — New York Medical Record. HYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL DISEASES. Syphilis and the Venereal Diseases. By James Nevins Hyde, M.D., Professor of Skin and Venereal Diseases, and Frank H. Mont- gomery, M.D., Lecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College, Chicago, 111. 618 pages, profusely illustrated. Cloth, $2.50 net. " We can commend this manual to the student as a help to him in his study of venereal diseases. ' ' — Liverpool Medico- Chirurgical Journal. "The best student's manual which has appeared on the subject." — St. Leuis Medical and Surgical Journal. INTERNATIONAL TEXT=BOOK OF SURGERY. In two volumes. By American and British authors. Edited by J. Collins Warren, M.D., LL.D., Professor of Surgery, Harvard Medical School, Boston; and A. Pearce Gould, M.S., F.R.C.S., Lecturer on Practical Sur- gery and Teacher of Operative Surgery, Middlesex Hospital Medical School, London, Eng. Vol. I. General Surgery. — Handsome octavo, 947 pages, with 458 beautiful illustrations and 9 lithographic plates. Vol. II. Special or Regional Surgery. — Handsome octavo, 1072 pages, with 471 beautiful illustrations and 8 lithographic plates. Prices per volume: Cloth, $5.00 net; Half Morocco, $6.00 net. 16 Medical Publications of W. B. Saunders. JACKSON'S DISEASES OF THE EYE. A Manual of Diseases of the Eye. By Edward Jackson, A.M., M.D., sometime Professor of Diseases of the Eye in the Philadelphia Polyclinic and College for Graduates in Medicine. 1 2mo volume of 535 P a g es > w i tn X 7S beautiful illustrations, mostly from drawings by the author. Cloth, $2.50 net. JACKSON AND GLEASON'S DISEASES OF THE EYE, NOSE, AND THROAT. Second Edition, Revised. Essentials of Refraction and Diseases of the Eye. By Edward Jackson, A.M., M.D., Professor of Diseases of the Eye in the Phila- delphia Polyclinic and College for Graduates in Medicine ; and — Essentials of Diseases of the Nose and Throat. By E. Bald- win Gleason, M.D., Surgeon-in-Charge of the Nose, Throat, and Ear Department of the Northern Dispensary of Philadelphia. Two volumes in one. Crown octavo, 290 pages; 124 illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question- Compends, page 22.] " Of great value to the beginner in these branches. The authors are both capable men, and know what a student most needs." — Medical Record, New York. KEATING'S DICTIONARY. Second Edition, Revised. A New Pronouncing Dictionary of Medicine, with Phonetic Pronunciation, Accentuation, Etymology, etc. By John M. Keating, M.D., LL.D., Fellow of the College of Physicians of Phila- delphia, and Henry Hamilton ; with the collaboration of J. Chal- mers DaCosta, M.D., and Frederick A. Packard, M.D. With an Appendix containi g Tables of Bacilli, Micrococci, Leucoma'ines, Ptomaines, etc. One volume of over 800 pages. Prices, with Ready- Reference Index: Cloth, $5.00 net; Sheep or Half Morocco, $6.00 net. Without Patent Index: Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net. "I am much pleased with Keating's Dictionary, and shall take pleasure in recommend- ing it to my classes." — Henry M. Lyman, M. D., Professor of the Principles and Practice <9f Medicine, Rush Medical College, Chicago, III. KEATING'S LIFE INSURANCE. How to Examine for Life Insurance. By John M. Keating, M. D., Fellow of the College of Physicians of Philadelphia; Vice- President of the American Pediatric Society; Ex- President of the Association of Life Insurance Medical Directors. Royal octavo, 211 pages ; with two large half-tone illustrations, and a plate prepared by Dr. McClellan from special dissections ; also, numerous other illustra- tions. Cloth, $2.00 net. KEEN'S OPERATION BLANK. Second Edition, Revised Form. An Operation Blank, with Lists of Instruments, etc., Required in Various Operations. Prepared by W. W. Keen, M.D., LL.D., Professor of the Principles of Surgery in Jefferson Medical College, Philadelphia. Price per pad, blanks for fifty operations, 50 cents net. Medical Publications of W. B. Saunders. 17 KEEN ON THE SURGERY OF TYPHOID FEVER. The Surgical Complications and Sequels of Typhoid Fever. By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Sur- gery and of Clinical Surgery, Jefferson Medical College, Philadelphia; Corresponding Member of the Societe de Chirurgie, Paris ; Honorary Member of the Societe Beige de Chirurgie, etc. Octavo volume of" 386 pages, illustrated. Cloth, $3.00 net. " This is probably the first and only work in the English language that gives the reader a clear view of what typhoid fever really is, and what it does and can do to the human organism. This book should be in the possession of every medical man in America." — American Medico-Surgical Bulletin. KYLE ON THE NOSE AND THROAT. Diseases of the Nose and Throat. By D. Braden Kyle, M.D., Clinical Professor of Laryngology and Rhinology, Jefferson Medical College, Philadelphia ; Consulting Laryngologist, Rhinologist, and Otologist, St. Agnes' Hospital. Handsome octavo volume of about 630 pages, with over 150 illustrations and 6 lithographic plates. Price, Cloth, $4.00 net; Half Morocco, $5.00 net. LAINE'S TEMPERATURE CHART. Temperature Chart. Prepared by D. T. Laine, M.D. Size 8x13^ inches. A conveniently arranged Chart for recording Temperature, with columns for daily amounts of Urinary and Fecal Excretions, Food, Remarks, etc. On the back of each chart is given in full the method of Brand in the treatment of Typhoid Fever. Price, per pad of 25 charts, 50 cents net. " To the busy practitioner this chart will be found of great value in fever cases, and especially for cases of typhoid." — Indian Lancet, Calcutta. LEVY AND KLEMPERER'S CLINICAL BACTERIOLOGY. The Elements of Clinical Bacteriology. By Dr. Ernst Levy, Profes- sor in the University of Strassburg, and Felix Klemperer, Privat docent in the University of Strassburg. Translated and edited by Augustus A. Eshner, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic. Octavo, 440 pages, fully illustrated. Cloth, $. net. LOCKWOOD'S PRACTICE OF MEDICINE. A Manual of the Practice of Medicine. By George Roe Lock- wood, M.D., Professor of Practice in the Woman's Medical College of the New York Infirmary, etc. 935 pages, with 75 illustrations in the text, and 22 full-page plates. Cloth, $2.50 net. " Gives in a most concise manner the points essential to treatment usually enumerated in the most elaborate works." — Massachusetts Medical Journal. LONG'S SYLLABUS OF GYNECOLOGY. A Syllabus of Gynecology, arranged in Conformity with "An American Text=Book of Gynecology." By J. W. Long, M.D., Professor of Diseases of Women and Children, Medical College of Virginia, etc. Cloth, interleaved, $1.00 net. " The book is certainly an admirable resume of what every gynecological student and practitioner should know, and will prove of value not only to those who have the ' American Text-Book of Gynecology,' but to others as well." — Brooklyn Medical Journal. 2 18 Medical Publications of W. B. Saunders. MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT. Surgical Diagnosis and Treatment. By J. W. Macdonald, M.D. Edin., F.R. C.S., Edin., Professor of the Practice of Surgery and of Clinical Surgery in Hamline University; Visiting Surgeon to St. Barnabas' Hospital, Minneapolis, etc. Handsome octavo volume of 800 pages, profusely illustrated. Cloth, $5.00 net; Half Morocco, So. 00 net. " A thorough and complete work on surgical diagnosis and treatment, free from pad- ding, full of valuable material, and in accord with the surgical teaching of the day." — The Medical Netos, A T ew York. " The work is brimful of just the kind of Practical information that is useful alike to students and practitioners. It is a pleasure to commend the bock because of its intrinsic value to the medical practitioner." — Cincinnati Lancet-Clinic MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE. Pathological Technique. A Practical Manual for Laboratory Work in Pathology, Bacteriology, and Morbid Anatomy, with chapters on Post-Mortem Technique and the Performance of Autopsies. By Frank B. Mallory, A.M., M.D., Assistant Professor of Pathology, Harvard University Medical School, Boston; and James H. Wright, A.M., M.D., Instructor in Pathology, Harvard University Medical School, Boston. Octavo volume of 396 pages, handsomely illustrated. Cloth, $2.50 net. " I have been looking forward to the publication of this book, and I am glsd to say that I find it to be a most useful laboratory and post-mortem guide, full of practical information, and well up to date." — William H. Welch, Professor of Pathology, Johns Hopkins Uni- versity, Baltimore, Md. MARTIN'S MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. Second Edition, Revised. Essentials of Minor Surgery, Bandaging, and Venereal Diseases. By Edward Martin, A.M., M.D., Clinical Professor of Genito-Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 166 pages, with 78 illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question- Compends, page 23.] "A very practical and systematic study of the subjects, and shows the author's famil- iarity with the needs of students." — Therapeutic Gazette. MARTIN'S SURGERY. Seventh Edition, Revised. Essentials of Surgery. Containing also Venereal Diseases, Surgi- cal Landmarks, Minor and Operative Surgery, and a complete de- scription, with illustrations, of the Handkerchief and Roller Bandages. By Edward Martin, A.M., M.D., Clinical Professor of Genito- Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 342 pages, illustrated. With an Appendix on the preparation of the materials used in Antiseptic Surgery, etc., and a chapter on Appendicitis. Cloth, $1.00 net; interleaved for notes, $1.25 net [See Saunders'' Question- Compends, page 23.] "Contains all necessary essentials of modern surgery in a comparatively small space. Its style is interesting, and its illustrations are admirable." — Medical and Surgical Reporter. Medical Publications of W. B. Saunders. 19 McFARLAND'S PATHOGENIC BACTERIA. Second Edition, Re- vised and Greatly Enlarged. Text=Book upon the Pathogenic Bacteria. By Joseph McFar- land, M. D., Professor of Pathology and Bacteriology in the Medico- Chirurgical College of Philadelphia, etc. Octavo volume of 497 pages, finely illustrated. Cloth, $2.50 net. " Dr. McFarland has treated the subject in a systematic manner, and has succeeded in presenting in a concise and readable form the essentials of bacteriology up to date. Alto- gether, the book is a satisfactory one, and I shall take pleasure in recommending it to the students of Trinity College." — H. B. Anderson, M.D. , Professor of Pathology and Bac- teriology, Trinity Medical College, Toronto. MEIGS ON FEEDING IN INFANCY. Feeding in Early Infancy. By Arthur V. Meigs, M.D. Bound in limp cloth, flush edges, 25 cents net. "This pamphlet is worth many times over its price to the physician. The author's experiments and conclusions are original, and have been the means of doing much good."— Medical Bulletin. MOORE'S ORTHOPEDIC SURGERY. A Manual of Orthopedic Surgery. By James E. Moore, M.D., Professor of Orthopedics and Adjunct Professor of Clinical Surgery, University of Minnesota, College of Medicine and Surgery. Octavo volume of 356 pages, handsomely illustrated. Cloth, $2.50 net. "A most attractive work. The illustrations and the care with which the book is adapted to the wants of the general practitioner and the student are worthy of great praise." — Chicago Medical Recorder. "A very demonstrative work, every illustration of which conveys a lesson. The work is a most excellent and commendable one, which we can certainly endorse with pleasure." — St. Louis Medical and Surgical Journal. MORRIS'S MATERIA MEDICA AND THERAPEUTICS. Fifth Edition, Revised. Essentials of Materia Medica, Therapeutics, and Prescription Writing. By Henrv Morris, M.D., late Demonstrator of Thera- peutics, Jefferson Medical College, Philadelphia ; Fellow of the College of Physicians, Philadelphia, etc. Crown octavo, 288 pages. Cloth, $1.00 ; interleaved for notes, $1.25. [See Saunders' Question- Compends, page 22.] " This work, already excellent in the old edition, has been largely improved by revi- sion. " — American Practitioner and News. MORRIS, WOLFF, AND POWELL'S PRACTICE OF MEDICINE, Third Edition, Revised. Essentials of the Practice of Medicine. By Henry Morris, M.D., late Demonstrator of Therapeutics, Jefferson Medical College, Phila- delphia ; with an Appendix on the Clinical and Microscopic Examina- tion of Urine, by Lawrence Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, Philadelphia. Enlarged by some 300 essen- tial formulas collected and arranged by William M. Powell, M.D. Post-octavo, 488 pages. Cloth, $2.00. [See Saunders' Question- Compends, page 22.] " The teaching is sound, the presentation graphic ; matter full as can be desired, and Style attractive." — American Practitioner and News. 20 Medical Publications of W. B. Saunders. MORTEN'S NURSE'S DICTIONARY. Nurse's Dictionary of Medical Terms and Nursing Treat- ment. Containing Definitions of the Principal Medical and Nursing Terms and Abbreviations ; of the Instruments, Drugs, Diseases, Acci- dents, Treatments, Operations, Foods, Appliances, etc. encountered in the ward or in the sick-room. By Honnor Morten, author of "How to Become a Nurse," etc. i6mo, 140 pages. Cloth, $1.00. " A handy, compact little volume, containing a large amount of general information, all of which is arranged in dictionary or encyclopedic form, thus facilitating quick reference. It is certainly of value to those for whose use it is published." — Chicago Clinical Review. NANCREDE'S ANATOMY. Sixth Edition, Thoroughly Revised. Essentials of Anatomy, including the Anatomy of the Viscera. By Charles B. Nancrede, M.D., LL.D., Professor of Surgery and of Clinical Surgery in the University of Michigan, Ann Arbor. Crown octavo, 420 pages; 151 illustrations. Based upon Gray's Anatomy. Cloth, Si. 00 net ; interleaved for notes, $1.25 net. [See Sounders' Question- Compends, page 23.] " For self-quizzing and keeping fresh in mind the knowledge of anatomy gained at school, it would not be easy to speak of it in terms too favorable." — American Practitioner. NANCREDE'S ANATOMY AND DISSECTION. Fourth Edition. Essentials of Anatomy and Manual of Practical Dissection. By Charles B. Nancrede, M.D., LL.D., Professor of Surgery and of Clinical Surgery, University of Michigan, Ann Arbor. Post-octavo ; 500 pages, with full-page lithographic plates in colors, and nearly 200 illustrations. Extra Cloth (or Oilcloth for dissection-room), $2.00 net. " It may in many respects be considered an epitome of Gray's popular work on general anatomy, at the same time having some distinguishing characteristics of its own to commend it. The plates are of more than ordinary excellence, and are of especial value to students in their work in the dissecting room." — Journal of the American Medical Association. NANCREDE'S PRINCIPLES OF SURGERY. Lectures on the Principles of Surgery. By Chas. B. Nancrede, M.D., LL.D., Professor of Surgery and of Clinical Surgery, Univer- sity of Michigan, Ann Arbor. Octavo volume of 398 pages, illustrated. Cloth, $ 2 - 5° net. NORRIS'S SYLLABUS OF OBSTETRICS. Third Edition, Revised. Syllabus of Obstetrical Lectures in the Medical Department of the University of Pennsylvania. By Richard C. Norris, A.M., M.D., Demonstrator of Obstetrics, University of Pennsylvania. Crown octavo, 222 pages. Cloth, interleaved for notes, $2.00 net. PENROSE'S DISEASES OF WOMEN. Third Edition, Revised. A Text=Book of Diseases of Women. By Charles B. Penrose, M. D., Ph.D., Formerly Professor of Gynecology in the University of Pennsylvania ; Surgeon to the Gynecean Hospital, Philadelphia. Octavo volume of 531 pages, handsomely illustrated. Cloth, $3.75 net. "I shall value very highly the copy of Penrose's 'Diseases of Women' received. I have already recommended it to my class as THE BEST book."— Howard A. Kelly, Professor of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Md. Medical Publications of W. B. Saunders. 21 POWELL'S DISEASES OF CHILDREN. Second Edition. Essentials of Diseases of Children. By William M. Powell, M.D., Attending Physician to the Mercer House for Invalid Women at Atlantic City, N. J. ; late Physician to the Clinic for the Diseases of Children in the Hospital of the University of Pennsylvania. Crown octavo, 222 pages. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question- Comjends, page 21.] "Contains the gist of all the best works in the department to which it relates."— American Practitioner and News. PRINGLE'S SKIN DISEASES AND SYPHILITIC AFFECTIONS. Pictorial Atlas of Skin Diseases and Syphilitic Affections (American Edition). Translation from the French. Edited by J. J. Pringle, M.B., F.R.C.P., Assistant Physician to the Middlesex Hospital, London. Photo-lithochromes from the famous models in the Museum of the Saint-Louis Hospital, Paris, with explanatory wood- cuts and text. In 12 Parts. Price per Part, $3.00. Complete in one volume, Half Morocco binding, $40.00 net. " I strongly recommend this Atlas. The plates are exceedingly well executed, and will be of great value to all studying dermatology." — Stephen Mackenzie, M.D. "The introduction of explanatory wood-cuts in the text is a novel and most important feature which greatly furthers the easier understanding of the excellent plates, than which nothing, we venture to say, has been seen better in point of correctness, beauty, and general merit." — New York Medical Journal. PRYOR— PELVIC INFLAMMATIONS. The Treatment of Pelvic Inflammations through the Vagina. By W. R. Pryor, M.D., Professor of Gynecology in New York Poly- clinic. 121110, 248 pages, handsomely illustrated. Cloth, $2.00 net. " This subject, which has recently been so thoroughly canvassed in high gynecological circles, is made available in this volume to the general practitioner and student. Nothing is too minute for mention and nothing is taken for granted ; consequently the book is of the utmost value. The illustrations and the technique are beyond criticism." — Chicago Medical Recorder. PYE'S BANDAGING. Elementary Bandaging and Surgical Dressing. With Direc- tions concerning the Immediate Treatment of Cases of Emergency. For the use of Dressers and Nurses. By Walter Pye, F.R.C.S., late Surgeon to St. Mary's Hospital, London. Small 121110, with over 80 illustrations. Cloth, flexible covers, 75 cents net. "The directions are clear and the illustrations are good."— London Lancet. " The author writes well, the diagrams are clear, and the book itself is small and port- able, although the paper and type are good." — British Medical Journal. RAYMOND'S PHYSIOLOGY. A Manual of Physiology. By Joseph H. Raymond, A.M., M.D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital ; Director of Physiology in the Hoagland Laboratory, etc. 382 pages, with 102 illustrations in the text, and 4 full-page colored plates. Cloth, $1.25 net. " Extremely well gotten up, and the illustrations have been selected with care. The text is fully abreast with modern physiology." — British Medical Journal. >AUNDERS' Question Compends Arranged in Question and Answer Form, HTHE MOST COMPLETE AND BEST ILLUSTRATED SERIES OF COMPENDS EVER ISSUED. Now the Standard Authorities in Medical Literature .... with Students and Practitioners in every City of the United States and Canada* ^> ^ OVER 175,000 COPIES SOLD. ^ THE REASON WHY. They are the advance guard of "Student's Helps" — that DO help. They are the leaders in their special line, well and authoritatively written by able men, who, as teachers in the large colleges, know exactly what is wanted by a student preparing for his examinations. The judgment exercised in the selection of authors is fully demonstrated by their professional standing. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of them have become Professors and Lecturers in their respective colleges. Each book is of convenient size (5x7 inches), containing on an average 250 pages, profusely illustrated, and elegantly printed in clear, readable type, on fine paper. The entire series, numbering twenty-three volumes, has been kept thoroughly revised and enlarged when necessary, many of the books being in their fifth and sixth editions. TO SUM UP. Although there ar£ numerous other Quizzes, Manuals, Aids, etc. in the market, none of them approach the " Blue Series of Question Compends;" and the claim is made for the following points of excellence : 1. Professional distinction and reputation of authors. 2. Conciseness, clearness, and soundness of treatment. 3. Quality of illustrations, paper, printing, and binding. Any cf these Compends will be mailed on receipt of price (see next page for List). Oaunders' v^uestion-Compend Series* Price, Cloth, $1.00 per copy, except when otherwise noted. "Where the work of preparing students' manuals is to end we cannot say, but the Saunders Series, in our opinion, bears off the palm at present."— New York Medical Record. 1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M.D. Fourth edition, revised and enlarged. ($1.00 net.) 2. ESSENTIALS OF SURGERY. By Edward Martin, M. D. Seventh edition, revised, with an Appendix and a chapter on Appendicitis. ($i.oo net.) 3. ESSENTIALS OF ANATOMY. By Chari.es B. Nancrede, M.D. Sixth edition, thoroughly revised and enlarged. ($i.oo net.) 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. By Lawrence Wolff, M.D. Fifth edition, revised. (JSi.oo net.) 5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M.D. Fourth edition, revised and enlarged. 6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E. Armand Semple, M.D. 7. ESSENTIALS OF MATERIA MED1CA, THERAPEUTICS, AND PRE- SCRIPTION=WRITING. By Henry Morris, M.D. Fifth edition, revised. 8. 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M.D. An Appendix on Urine Examination. By Lawrence Wolff, M.D. Third edition, enlarged by some 300 Essential Formulas, selected from eminent authorities, by Wm. M. Powell, M.D. (Double number, $2.00.) 10. ESSENTIALS OF GYNAECOLOGY. By Edwin B. Cragin, M.D. Fourth edition, revised. 11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon, M.D. Fourth edition, revised and enlarged. ($1.00 net.) 12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. By Edward Martin, M.D. Second ed., revised and enlarged. 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. By C. E. Armand Semple, M.D. 14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. By Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised. 15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, M.D. Second edition. 16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff, M.D. Colored " Vogel Scale." (75 cents. ) 17. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D., and A. A. Eshner, M.D. Second edition, thoroughly revised. ($1.00 net.) 18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre. Second edition, revised and enlarged. 20. ESSENTIALS OF BACTERIOLOGY. By M. V. Ball, M.D. Third edition, revised. 21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C. Shaw, M.D. Third edition, revised. 22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockway, M.D. Second edition, revised. ($1.00 net.) 23. ESSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D. , and Edward S. Lawrance, M.D. 24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M.D. Second edition, revised and greatly enlarged. Pamphlet containing specimen pages, etc. sent free upon application. Saunders' New Series of Manuals for Students and Practitioners. * I 'HAT there exists a need for thoroughly reliable hand-books on the leading branches of Medicine and Surgery is a fact amply demonstrated by the favor with which the SAUNDERS NEW SERIES OF MANUALS have been received- by medical students and practitioners and by the Medical Press, These manuals are not merely condensations from present literature, but are ably written by well-known authors and practitioners, most of them being teachers in representative American colleges. Each volume is concisely and authoritatively written and exhaustive in detail, without being encumbered with the introduction of "cases," which so largely expand the ordinary text-book. These manuals will therefore form an admirable collection of advanced lectures, useful alike to the medical student and the practitioner: to the latter, too busy to search through page after page of elaborate treatises for what he wants to know, they will prove of inestimable value ; to the former they will afford safe guides to the essential points of study. The SAUNDERS NEW SERIES OF MANUALS are conceded to be superior to any similar books now on the market. No other manuals afford so much infor- mation in such a concise and available form. A liberal expenditure has enabled the publisher to render the mechanical portion of the work worthy of the high literary standard attained by these books. Any of these Manuals will be mailed on receipt of price (see next page for List). Saunders' New Series of Manuals* VOLUMES PUBLISHED. PHYSIOLOGY. By Joseph Howard Raymond, A.M., M.D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital ; Director of Physiology in the Hoagland Laboratory, etc. Illustrated. Cloth, $1.25 net. SURGERY, General and Operative. By John Chalmers DaCosta, M.D., Clini- cal Professor of Surgery, Jefferson Medical College, Philadelphia; Surgeon to the Philadelphia Hospital, etc. Second edition, thoroughly revised and greatly enlarged. Octavo, 911 pages, profusely illustrated. Cloth, $4.00 net ; Half Morocco, $5.00 net. DOSE=BOOK AND MANUAL OF PRESCRIPTI0N=WRIT1NG. By E. Q. Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila- delphia. Illustrated. Cloth, $1.25 net. SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and to the New York German Polildinik, etc. Illustrated. Cloth, $1.25 net. MEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of Insti- tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila- delphia. Illustrated. Cloth, $1.50 net. SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M.D., Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M.D., Lecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College, Chicago. Profusely illustrated. Cloth, $2.50 net. PRACTICE OF MEDICINE. By George Roe Lockwood, M.D., Professor of Practice in the Woman's Medical College of the New York Infirmary; Instructor in Physical Diagnosis in the Medical Department of Columbia College, etc. Illustrated. Cloth, #2.50 net. MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of Anatomy and Demonstrator of Anatomy, Medical Department of the New York University, etc. Beautifully illustrated. Cloth, $2.50 net. MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant Demonstrator of Obstetrics, University of Pennsylvania ; Chief of Gynecological Dis- pensary, Pennsylvania Hospital, etc. Profusely illustrated. Cloth, $2.50 net. DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant Surgeon to Middlesex Hospital and Surgeon to Chelsea Hospital, London; and Arthur E. Giles, M.D. , B. Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, London. Handsomely illustrated. Cloth, 32.50 net. VOLUMES IN PREPARATION. NERVOUS DISEASES. By Charles W. Burr, M.D., Clinical Professor of Nervous Diseases, Medico-Chirurgical College, Philadelphia ; Pathologist to the Orthopaedic Hospital and Infirmary for Nervous Diseases ; Visiting Physician to the St. Joseph Hospital, etc. *** There will be published in the same series, at short intervals, carefully-prepared works on various subjects by prominent specialists. Pamphlet containing specimen pages, etc. sent free upon application. 26 Medical Publications of W. JB. Saunders. SAUNDBY'S RENAL AND URINARY DISEASES. Lectures on Renal and Urinary Diseases. By Robert Saundby, M.D. Edin., Fellow of the Royal College of Physicians, London, and of the Royal Medico-Chirurgical Society ; Physician to the General Hospital ; Consulting Physician to the Eye Hospital and to the Hos- pital for Diseases of Women; Professor of Medicine in Mason College, Birmingham, etc. Octavo volume of 434 pages, with numerous illus- trations and 4 colored plates. Cloth, $2.50 net. " The volume makes a favorable impression at once. The style is clear and succinct. We cannot find any part of the subject in which the views expressed are not carefully thought out and fortified by evidence drawn from the most recent sources. The book may be cordially recommended." — British Medical Journal. SAUNDERS' MEDICAL HAND=ATLASES. For full description of this series, with list of volumes and prices, see page 2. " Lehmann Medicinische Handatlanten belong to that class of books that are too good to be appropriated by any one nation." — Journal of Eye, Ear, and Throat Diseases. " The appearance of these works marks a new era in illustrated English medical works." — The Canadian Practitioner. SAUNDERS' POCKET MEDICAL FORMULARY. Fifth Edition, Revised. By William M. Powell, M.D., Attending Physician to the Mercer House for Invalid Women at Atlantic City, N. J. Containing 1800 formulae selected from the best-known authorities. With an Appen- dix containing Posological Table, Formulas and Doses for Hypo- dermic Medication, Poisons and their Antidotes, Diameters of the Female Pelvis and Foetal Head, Obstetrical Table, Diet List for Various Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- somely bound in flexible morocco, with side index, wallet, and flap. $i-75 net - "This little book, that can be conveniently carried in the pocket, contains an immense amount of material. It is very useful, and, as the name of the author of each prescription is given, is unusually reliable." — Medical Record, New York. SAYRE'S PHARMACY. Second Edition, Revised. Essentials of the Practice of Pharmacy. By Lucius E. Sayre, M.D., Professor of Pharmacy and Materia Medica in the University of Kansas. Crown octavo, 200 pages. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question- Compends, page 21.] " The topics are treated in a simple, practical manner, and the work forms a very useful Student's manual." — Boston Medical and Surgical Journal. SCUDDER'S FRACTURES. The Treatment of Fractures. By Chas. L. Scudder, M.D., As- sistant in Clinical and Operative Surgery, Harvard Medical School. Octavo, 400 pages, with nearly 600 original illustrations. Cloth, $ net. Medical Publications of W. B. Saunders. 27 SEMPLE'S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. Essentials of Legal Medicine, Toxicology, and Hygiene. By C. E. Armand Semple, B. A., M. B. Cantab., M. R. C. P. Lond., Physician to the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 2 1 2 pages ; 130 illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question- Compends, page 21.] " No general practitioner or student can afford to be without this valuable work. The subjects are dealt with by a masterly hand." — London Hospital Gazette. SEMPLE'S PATHOLOGY AND MORBID ANATOMY. Essentials of Pathology and Morbid Anatomy. By C. E. Armand Semple, B.A., M.B. Cantab., M.R.C.P. Lond., Physician to the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 174 pages; illustrated. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question- Compends, page 21.] " Should take its place among the standard volumes on the bookshelf of both student and practitioner." — London Hospital Gazette. SENN'S GENITOURINARY TUBERCULOSIS. Tuberculosis of the Genito=Urinary Organs, Male and Female. By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical College, Chicago. Handsome octavo volume of 320 pages, illustrated. Cloth, $3.00 net. " An important book upon an important subject, and written by a man of mature judg- ment and wide experience. The author has given us an instructive book upon one of the most important subjects of the day." — Clinical Reporter. " A work which adds another to the many obligations the profession owes the talented author." — Chicago Medical Recorder. SENN'S SYLLABUS OF SURGERY. A Syllabus of Lectures on the Practice of Surgery, arranged in conformity with " An American Text=Book of Surgery." By Nicholas Senn, M.D., Ph.D., Professor of the Practice of Surgery and of Clinical Surgery in Rush Medical College, Chicago. Cloth, $2.00. " This syllabus will be found of service by the teacher as well as the student, the work being superbly done. There is no praise too high for it. No surgeon should be without it." — New York Medical Times. SENN'S TUMORS. Pathology and Surgical Treatment of Tumors. By N. Senn, M.D., Ph.D., LL.D., Professor of Surgery and of Clinical Surgery, Rush Medical College ; Professor of Surgery, Chicago Polyclinic ; Attending Surgeon to Presbyterian Hospital : Surgeon-in-Chief, St. Joseph's Hospital, Chicago. Octavo volume of 710 pages, with 515 engravings, including full-page colored plates. New and Revised Edi- tion in Preparation. " The most exhaustive of any recent book in English on this subject. It is well illus- trated, and will doubtless remain as the principal monograph on the subject in our language for some years. The book is handsomely illustrated and printed, and the author has given a notable and lasting contribution to surgery." — -Journal op the American Medical Association. 28 Medical Publications of W. B. Saunders. SHAW'S NERVOUS DISEASES AND INSANITY. Third Edition, Revised. Essentials of Nervous Diseases and Insanity. By John C. Shaw, M.D., Clinical Professor of Diseases of the Mind and Nervous System, Long Island College Hospital Medical School ; Consulting Neurologist to St. Catherine's Hospital and to the Long Island College Hospital. Crown octavo, 186 pages; 48 original illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question- Commends, page 21.] "Clearly and intelligently written." — Boston Medical and Surgical Journal. "There is a mass of valuable material crowded into this small compass." — American Medico- Swgical Bulletin. STARR'S DIETS FOR INFANTS AND CHILDREN. Diets for Infants and Children in Health and in Disease. By Louis Starr, M.D., Editor of "An American Text-Book of the Diseases of Children." 230 blanks (pocket-book size), perforated and neatly bound in flexible morocco. $1.25 net. The first series of blanks are prepared for the first seven months of infant life ; each blank indicates the ingredients, but not the quantities, of the food, the latter directions being left for the physician. After the seventh month, modifications being less necessary, the diet lists are printed in full. Formulas for the preparation of diluents and foods are appended. STELW AGON'S DISEASES OF THE SKIN. Fourth Ed., Revised. Essentials of Diseases of the Skin. By Henry W. Stelwagon, M.D., Clinical Professor of Dermatology in the Jefferson Medical College, Philadelphia; Dermatologist to the Philadelphia Hospital; Physician to the Skin Department of the Howard Hospital, etc. Crown octavo, 276 pages; 88 illustrations. Cloth, $1.00 net; inter- leaved for notes, $1.25 net. [See Saunders' Question- Commends, page 21.] " The best student's manual on skin diseases we have yet seen." — Times and Register. STENGEL'S PATHOLOGY. Second Edition. A Text=Book of Pathology. By Alfred Stengel, M.D., Professor of Clinical Medicine in the University of Pennsylvania; Physician to the Philadelphia Hospital ; Physician to the Children's Hospital, etc. Handsome octavo volume of 848 pages, with nearly 400 illustrations, many of them in colors. Cloth, $4.00 net; Half Morocco, $5.00 net. STEVENS' MATERIA MEDICA AND THERAPEUTICS. Second Edition, Revised. A Manual of Materia Medica and Therapeutics. By A. A. Stevens, A.M., M.D., Lecturer on Terminology and Instructor in Phvsical Diagnosis in the University of Pennsylvania; Professor of Pathology in the Woman's Medical College of Pennsylvania. Post- octavo, 445 pages. Flexible leather, $2.25. •'The author has faithfully presented modern therapeutics in a comprehensive work and, while intended particularly for the use of students, it will be found a reliable guide and sufficiently comprehensive for the physician in practice. "— University Medical Magazine. Medical Publications of W. B. Saunders. 29 STEVENS' PRACTICE OF MEDICINE. Fifth Edition, Revised. A Manual of the Practice of Medicine. By A. A. Stevens, A. M., M. D., Lecturer on Terminology and Instructor in Physical Diagnosis in the University of Pennsylvania; Professor of Pathology in the Woman's Medical College of Pennsylvania. Specially intended for students preparing for graduation and hospital examinations. Post- octavo, 519 pages; illustrated. Flexible leather, $2.00 net. " The frequency with which new editions of this manual are demanded bespeaks its popularity. It is an excellent condensation of the essentials of medical practice for the student, and maybe found also an excellent reminder for the busy physician." Buffalo Medical Journal. STEWART'S PHYSIOLOGY. Third Edition, Revised. A Manual of Physiology, with Practical Exercises. For Students and Practitioners. By G. N. Stewart, M.A., M.D., D.Sc, lately Examiner in Physiology, University of Aberdeen, and of the New Museums, Cambridge University; Professor of Physiology in the Western Reserve University, Cleveland, Ohio. Octavo volume of 848 pages; 300 illustrations in the text, and 5 colored plates. Cloth, $3.75 net. " It will make its way by sheer force of merit, and amply deserves to do so. It is one of the very best English text-books on the subject." — London Lancet. "Of the many text-books of physiology published, we do not know of one that so nearly comes up to the ideal as does Prof. Stewart's volume." — British Medical Journal. STEWART AND LAWRANCE'S MEDICAL ELECTRICITY. Essentials of Medical Electricity. By D. D. Stewart, M.D., Demonstrator of Diseases of the Nervous System and Chief of the Neurological Clinic in the Jefferson Medical. College; and E. S. Lawrance, M.D., Chief of the Electrical Clinic and Assistant Demon- strator of Diseases of the Nervous System in the Jefferson Medical College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question- Compends, page 21.] " Throughout the whole brief space at their command the authors show a discriminating knowledge of their subject." — Medical A T ews. STONEY'S NURSING. Second Edition, Revised. Practical Points in Nursing. For Nurses in Private Practice, By Emily A. M. Stoney, Graduate of the Training-School for Nurses, Lawrence, Mass.; late Superintendent of the Training-School for Nurses, Carney Hospital, South Boston, Mass. 456 pages, illustrated with 73 engravings in the text, and 8 colored and half-tone plates. Cloth, $1.75 net. " There are few books intended for non -professional readers which can be so cordially endorsed by a medical journal as can this one." — Therapeutic Gazette. " This is a well-written, eminently practical volume, which covers the entire range of private nursing as distinguished from hospital nursing, and instructs the nurse how best to meet the various emergencies which may arise, and how to prepare everything ordinarily needed in the illness of her patient." — American Journal of Obstetrics and Diseases of Women and Children. " It is a work that the physician can place in the hands of his private nurses with the assurance of benefit." — Ohio Medical Journal. 30 Medical Publications of W. B. Saunders, STONEY'S MATERIA MEDICA FOR NURSES. Materia Medica for Nurses. By Emily A. M. Stoney, Graduate of the Training-School for Nurses, Lawrence, Mass. ; late Superintendent of the Training-School for Nurses, Carney Hospital, South Boston, Mass. Handsome octavo volume of 306 pages. Cloth, $1.50 net. The present book differs from other similar works in several features, all of which are intended to render it more practical and generally useful. The general plan of the contents follows the lines laid down in training-schools for nurses, but the book contains much use- ful matter not usually included in works of this character, such as Poison-emergencies, Ready Dose-list, Weights and Measures, etc., as well as a Glossary, defining all the terms used in Materia Medica, and describing all the latest drugs and remedies, which have been generally neglected by other books of the kind. SUTTON AND GILES' DISEASES OF WOMEN. Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital, London; and Arthur E. Giles, M.D., B.Sc. Lond., F.R. C.S. Edin., Assistant Surgeon to Chelsea Hospital, London. 436 pages, hand- somely illustrated. Cloth, $2.50 net. "The text has been carefully prepared. Nothing essential has been omitted, and its teachings are those recommended by the leading authorities of the day." — Journal of the American Medical Association. THOMAS'S DIET LISTS. Second Edition, Revised. Diet Lists and Sick=Room Dietary. By Jerome B. Thomas, M.D., Visiting Physician to the Home for Friendless Women and Children and to the Newsboys' Home ; Assistant Visiting Physician to the Kings County Hospital. Cloth, $1.50. Send for sample sheet. THORNTON'S DOSE=BOOK AND PRESCRIPTION=WRITING. Dose=Book and Manual of Prescription=Writing. By E. Q. Thornton, M.D., Demonstrator of Therapeutics, Je'fferson Medical College, Philadelphia. 334 pages, illustrated. Cloth, $1.25 net. "Full of practical suggestions; will take its place in the front rank of works of this sort." — Aledical Record, New York. VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH. Diseases of the Stomach. By William W. Van Valzah, M.D., Professor of General Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic; and J. Douglas Nisbet, M.D., Adjunct Professor of General Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic. Octavo volume of 674 pages, illustrated. Cloth, $3.50 net. " Its chief claim lies in its clearness and general adaptability to the practical needs of the general practitioner or student. In these relations it is probably the best of the recent special works on diseases of the stomach." — Chicago Clinical Review. VECKI'S SEXUAL IMPOTENCE. The Pathology and Treatment of Sexual Impotence. By Victor G. Vecki, M.D. From the second German edition, revised and en- larged. Demi-octavo, 291 pages. Cloth, $2.00 net. The subject of impotence has seldom been treated in this country in the truly scientific spirit that it deserves. Dr. Vecki's work has long been favorably known, and the German book has received the highest consideration. This edition is more than a mere translation, for, although based on the German edition, it has been entirely rewritten in English. Medical Publications of W. B. Saunders. 31 VIERORDT'S MEDICAL DIAGNOSIS. Fourth Edition, Revised. Medical Diagnosis. By Dr. Oswald Vierordt, Professor of Medi- cine at the University of Heidelberg. Translated, with additions, from the fifth enlarged German edition, with the author's permission, by Francis H. Stuart, A. M., M. D. Handsome royal octavo volume of 603 pages; 194 fine wood-cuts in text, many of them in colors. Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net. " A treasury of practical information which will be found of daily use to every busy practitioner who will consult it." — C. A. LlNDSLEY, M.D., Professor of the Theory and Practice of Medici 'ne, Yale University. " Rarely is a book published with which a reviewer can find so little fault as with the volume before us. Each particular item in the consideration of an organ or apparatus, which is necessary to determine a diagnosis of any disease of that organ, is mentioned ; nothing seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and nervous system are especially full and valuable. The reviewer would repeat that the book is one of the best — probably the best — which has fallen into his hands." — University Medical Magazine. WARREN'S SURGICAL PATHOLOGY AND THERAPEUTICS. Second Edition. Surgical Pathology and Therapeutics. By John Collins Warren, M. D., LL.D., Professor of Surgery, Medical Department Harvard Uni- versity ; Surgeon to the Massachusetts General Hospital, etc. Handsome octavo volume of 832 pages; 136 relief and lithographic illustrations, 33 of which are printed in colors ; with an Appendix devoted to the Scientific Aids to Surgical Diagnosis, and a series of articles on Re- gional Bacteriology. Cloth, $5.00 net; Half Morocco, $6.00 net. "There is the work of Dr. Warren, which I think is the most creditable book on Surgical Pathology, and the most beautiful medical illustration of the bookmaker's art, that has ever been issued from the American press." — Dr. Roswell Park, in the Harvard Graduate Magazine. " A most striking and very excellent feature of this book is its illustrations. Without exception, from the point of accuracy and artistic merit, they are the best ever seen in a work of this kind. Many of those representing microscopic pictures are so perfect in their coloring and detail as almost to give the beholder the impression that he is looking down the barrel of a microscope at a well-mounted section." — Annals of Surgery. WOLFF ON EXAMINATION OF URINE. Essentials of Examination of Urine. By Lawrence Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, Philadelphia, etc. Colored (Vogel) urine scale and numerous illustrations. Crown octavo. Cloth, 75 cents. [See Saunders' Question- Compends, page 21.] " A very good work of its kind — very well suited to its purpose." — Times and Register. WOLFF'S MEDICAL CHEMISTRY. Fifth Edition, Revised. Essentials of Medical Chemistry, Organic and Inorganic. Containing also Questions on Medical Physics, Chemical Physiology, Analytical Processes, Urinalysis, and Toxicology. By Lawrence Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, Philadelphia, etc. Crown octavo, 222 pages. Cloth, $1.00 net; inter- leaved for notes, #1.25 net. [See Saunders'' Question- Compends, page 21.] " The scope of this work is certainly equal to that of the best course of lectures on Medical Chemistry." — Pharmaceutical Era. CLASSIFIED LIST Medical Publications W. B. SAUNDERS, 925 Walnut Street, Philadelphia. ANATOMY, EMBRYOLOGY, HISTOLOGY. Clarkson — A Text-Book of Histology, 1 1 Haynes — A Manual of Anatomy, ...15 Heisler — A Text- Book of Embryology, 15 Nancrede — Essentials of Anatomy, . . 20 Nancrede — Essentials of Anatomy and Manual of Practical Dissection, ... 20 Semple — Essentials of Pathology, . . 27 BACTERIOLOGY. Ball — Essentials of Bacteriology, ... S Crookshank — A Text-Book of Bacteri- ology, 12 Frothingham — Laboratory Guide, . . 13 Levy and Klemperer's Clinical Bacte- riology, 17 Mallory and Wright — Pathological Technique, 18 McFarland — Pathogenic Bacteria, . . iq CHARTS, DIET=LISTS, ETC. Griffith — Infant's Weight Chart, ... 14 Hart — Diet in Sickness and in Health, . 15 Keen — Operation Blank, 17 Laine — Temperature Chart, 17 Meigs — Feeding in Early Infancy, . . 19 Starr — Diets for Infants and Children, . 28 Thomas— Diet-Lists, 30 CHEMISTRY AND PHYSICS. Brockway — Essentials of Medical Phys- ics, 9 Wolff — Essentials of Medical Chemistry, 31 CHILDREN. An American Text-Book of Diseases of Children, 5 Griffith — Care of the Baby 14 Griffith — Infant's Weight Chart, ... 14 Meigs — Feeding in Early Infancy, . . 19 Powell — Essentials of Dis. of Children, 21 Starr — Diets for Infants and Children, . 28 DIAGNOSIS. Cohen and Eshner — Essentials of Di- agnosis, 11 Corwin — Physical Diagnosis, .... 11 Macdonald — Surgical Diagnosis and Treatment, 18 Vierordt — Medical Diagnosis 31 DICTIONARIES. Dorland — Pocket Dictionary, .... 12 Keating — Pronouncing Dictionary, . . 16 Morten — Nurse's Dictionary, .... 20 EYE, EAR, NOSE, AND THROAT. An American Text-Book of Diseases of the Eye, Ear, Nose, and Throat, . 5 De Schweinitz — Diseases of the Eye, . 12 Gleason — Essentials of Dis. of the Ear, 13 Jackson — Manual of Diseases of Eye, . 16 Jackson and Gleason — Essentials of Diseases of the Eye, Nose, and Throat, 16 Kyle — Diseases of the Nose and Throat, 17 GENITOURINARY. An American Text-Book of Genito- urinary and Skin Diseases, 6 Hyde and Montgomery — Syphilis and the Venereal Diseases, 15 Martin — Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . 18 Saundby — Renal and Urinary Diseases, 26 Senn — Genito-Urinary Tuberculosis, . 27 Vecki — Sexual Impotence, 30 GYNECOLOGY. American Text- Book of Gynecology, 6 Cragin — Essentials of Gynecology, . . II Garrigues — Diseases of Women, ... 13 Long — Syllabus of Gynecology, ... 17 Penrose — Diseases of Women, .... 20 Pryor — Pelvic Inflammations, .... 34 Sutton and Giles — Diseases of Women, 30 MATERIA MEDICA, PHARMACOL- OGY, AND THERAPEUTICS. An American Text-Book of Applied Therapeutics, 5 Butler — Text-Book of Materia Medica, Therapeutics and Pharmacology, ... 10 Cerna — Notes on the Newer Remedies, 10 Griffin — Materia Med. and Therapeutics, 14 Morris — Essentials of Materia Medica and Therapeutics, 19 Saunders' Pocket Medical Formulary, 26 Sayre — Essentials of Pharmacy, ... 26 Stevens — Essentials of Materia Medica and Therapeutics, 28 Stoney — Materia Medica for Nurses, . . 30 Thornton — I Jose- Book and Manual of Prescription-Writing, 30 MEDICAL JURISPRUDENCE AND TOXICOLOGY. Chapman — Medical Jurisprudence and Toxicology, 10 Semple — Essentials of Legal Medicine, Toxicology, and Hygiene, 27 Medical Publications of W. B. Saunders. 33 NERVOUS AND MENTAL DISEASES, ETC. Burr — Nervous Diseases, 9 Chapin — Compendium of Insanity, . . 10 Church and Peterson — Nervous and Mental Diseases, 10 Shaw — Essentials of Nervous Diseases and Insanity, 28 NURSING. An American Text-Book of Nursing, 31 Griffith— The Care of the Baby, ... 14 Hampton — Nursing, '4 Hart — Diet in Sickness and in Health, 15 Meigs — Feeding in Early Infancy, . . 19 Morten — Nurse's Dictionary 20 Stoney — Materia Medica for Nurses, . . 30 Stoney — Practical Points in Nursing, . 29 OBSTETRICS. An American Text-Book of Obstetrics, Ashton — Essentials of Obstetrics, Boisliniere — Obstetric Accident-, Dorland — Manual of Obstetrics, Hirst — Text- Book of Obstetrics, Norris — Syllabus of Obstetrics, . PATHOLOGY. An American Text-Book of Pathology, Mallory and Wright — Pathological Technique, Semple — Essentials of Pathology and Morbid Anatomy, Senn — Pathology and Surgical Treat- ment of Tumors, Stengel — Text-Book of Pathology, . . Warren — Surgical Pathology and Thera- peutics, PHYSIOLOGY. An American Text-Book of Physi- ology, Hare — Essentials of Physiology, . . . Raymond — Manual of Physiology, . . Stewart — Manual of Physiology, . . . PRACTICE OF MEDICINE. An American Text-Book of the The- ory and Practice of Medicine, .... An American Year-Book of Medicine and Surgery, Anders — Text-Book of the Practice of Medicine, Lockwood — Manual of the Practice of Medicine, .... Morris — Essentials of the Practice of Medicine, Stevens — Manual of the Practice of Medicine, SKIN AND VENEREAL. An American Text-Book of Genito- urinary and Skin Diseases, Hyde and Montgomery — Syphilis and the Venereal Diseases, Martin — Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . 18 Pringle — Pictorial Atlas of Skin Dis- eases and Syphilitic Affections, ... 21 Stelwagon — Essentials of Diseases of the Skin, 28 SURGERY. An American Text-Book of Surgery, 7 An American Year-Book of Medicine and Surgery, 8 Beck — -Fractures, 9 Beck — Manual of Surgical Asepsis, . . 9 DaCosta — Manual of Surgery, . ... 12 International Text-Book of Surgery, . 15 Keen— Operation Blank, 17 Keen — The Surgical Complications and Sequels of Typhoid Fever, 17 Macdonald — Surgical Diagnosis and Treatment, 18 Martin — Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . 18 Martin — Essentials of Surgery, .... 18 Moore — Orthopedic Surgery, 19 Nancrede — Principles of Surgery, . . 20 Pye — Bandaging and Surgical Dressing, 21 Scudder — Treatment of Fractures, . . 26 Senn — Genito-Urinary Tuberculosis, . 27 Senn— Syllabus of Surgery, 27 Senn — Pathology and Surgical Treat- ment of Tumors, . . 27 Warren — Surgical Pathology and Ther- apeutics, 3 1 URINE AND URINARY DISEASES. Saundby — Renal and Urinary Diseases, 26 I Wolff — Essentials of Examination of Urine, 3 1 MISCELLANEOUS. Abbott — Hygiene of Transmissible Dis- eases, ° Bastin — Laboratory Exercises in Bot- any, 9 Gould and Pyle — Anomalies and Curi- osities of Medicine, 13 Grafstrom — Massage, ....... 14 Keating — How to Examine for Life Insurance, ....... o - . 16 Rowland and Hedley — Archives of the Roentgen Ray, 2r Saunders' Medical Hand-Atlases. .2, 3, 4 Saunders' New Series of Manuals, 24, 25 Saunders' Pocket Medical Formulary, 26 Saunders' Question-Compends, . . 22, 23 Senn — Pathology and Surgical Treat- ment of Tumors, 27 Stewart and Lawrance — Essentials of Medical Electricity, 29 Thornton — Dose-Book and Manual of Prescription-Writing, 3° Van Valzah and Nisbet— Diseases of the Stomach, 3° Some of the Books in Preparation for Publication during 1900. AMERICAN Text-Book of Pa- thology. Edited by Ludvig Hektoen, M. D., Pro- fessor of Pathology, Rush Medical College, Chicago; and David Riesman, M. D., De- monstrator of Pathological Histology, Uni- versity of Pennsylvania. AMERICAN Text-Book of Legal Medicine and Toxicology. Edited by Frederick Peterson, M. D , Chief of Clinic, Nervous Department, College of Physicians and Surgeons, New York City ; and Walter S. Haines, M. D., Professor of Chemistry, Pharmacy, and Toxicology, Rush Medical College, Chicago. BOHM, DAV1DOFF, and HU- BER — A Text-Book of Human Histology. Including Microscopic Technic. By Dr. A. A. Bohm and Dr. M. von Davidoff, of the Anatomical Institute of Munich, and G. C. Hubkr, M. D., Junior Professor of Anat- omy and Histology, University of Michigan, Ann Arbor. EICHHORST — A Text-Book of the Practice of Medicine. By Dr. Herman Eichiiorst, Professor of Special Pathology and Therapeutics and Di- rector of the Medical Clinic, University of Zurich. Translated and edited by Augustus A. ESHNER, M. D., Professor of Clinical Medi- cine in the Philadelphia Polyclinic. FRIEDRICH — Rhinology, La- ryngology, and Otology in their Relations to General Medicine. By Dr. E. P. Friedrich, of the Univer- sity of Leipsig. Edited by H. Holbrook CURTIS, M. D., Consulting Surgeon to the New York Nose and Throat Hospital. McFARLAND — A Text-Book of Pathology. By Joseph McFarland, M.D., Professor of Pathology and Bacteriology, Medico-Chi- rurgical College, Philadelphia. OGDEN — Clinical Examination of the Urine. By J. Bergen Ogden, M.D., Assistant in Chemistry, Harvard Medical School. PYLE — A Manual of Personal Hygiene. Edited by Walter L. Pyle, M. D., Assis- tant Surgeon to Wills' Eye Hospital, Philada. SALINGER AND KALTEYER— Modern Medicine. By Julius L. Salinger, M. D., Demon- strator of Clinical Medicine, Jefferson Medi- cal College ; Chief of Medical Clinic, Jeffer- son College Hospital ; Attending Physician to Philadelphia Hospital; and F. J. Kalteyer, M. D., Assistant Demonstrator of Clinical Medicine, Jefferson Medical College; Assis- tant Pathologist to Philadelphia Hospital. SCUDDER — The Treatment of Fractures. By Charles L. Scudder, M. D., Assistant in Clinical and Operative Surgery, Harvard University. See page 26. SENN — Practical Surgery. By Nicholas Senn, M. D., Ph. D., LL. D., Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical College, Chi- cago. Octavo volume of about 800 pages, profusely illustrated. The Pathology and Treatment of Tumors. By Nicholas Senn, M. D., Ph. D., LL.D., Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical College, Chi- cago. A New and Thoroughly Revised Edi- tion in preparation. STENGEL AND WHITE— The Blood in its Clinical and Patho- logical Relations. By Alfred Stengel, M. D., Professor of Clinical Medicine, University of Pennsyl- vania; and C. Y. White, M. D., Instructor in Clinical Medicine University of Pennsylvania-* STEVENS — The Physical Diag- nosis of Diseases of the Chest. By A. A. Stevens, A. M., M. D., Lecturer on Terminology, and Instructor in Physical Diagnosis, University of Pennsylvania. STONEY— Surgical Technic for Nurses. By Emily A. M. Stoney, late Superin- tendent of the Training Schools for Nurses, Carney Hospital, SouthBoston, Mass. RD101 Beck B38 COLUMBIA UNIVERSITY LIBRARIES (hsl.stx) RD 101 B38 C.1 Fractures. . 2002103966